records request form dental

Patient Dental Records Release Authorization

Instructions for Use

• Complete all fields below to ensure the correct patient file is identified and processed.
• Submit the signed form via secure email, fax, or in-person delivery to the dental practice’s front office.
• Specify your preferred delivery method (electronic vs. physical copy) and ensure contact information is accurate to avoid processing delays.

Parties and Definitions

Patient Name: []
Date of Birth: []
Dental Practice Name: []
Practice Address: []

Operative Terms

1. Authorization: I hereby authorize the Dental Practice listed above to release my protected dental health information to the recipient identified below.
2. Recipient Information: Please send records to:
   • Name/Entity: [__________]
   • Email/Address: [__________]
   • Phone Number: [__________]
3. Scope of Records: I request the following information (select all that apply):
   • Entire dental record (including charting and notes)
   • Radiographs (X-rays/CBCT scans)
   • Treatment plans and estimates
   • Billing and insurance statements
   • Other: [__________]
4. Delivery Method: Please provide the records via:
   • Secure Email
   • Physical Paper Copy (via mail)
   • Pick-up in person
5. Revocation: I understand that I may revoke this authorization in writing at any time, except to the extent that the Dental Practice has already taken action in reliance on it.
6. Re-disclosure: I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state privacy laws.
7. Fees: I acknowledge that the Dental Practice may charge a reasonable, cost-based fee for the copying and transmission of these records, as permitted by applicable state law.

Signature and Acknowledgment

By signing below, I confirm that I am the patient or the patient’s legally authorized representative.

Signature: []
Printed Name: []
Relationship to Patient: []
Date: []

Legal Disclaimer: This document is a general framework and does not constitute legal advice. Please consult with qualified legal counsel to ensure compliance with HIPAA, state-specific privacy regulations, and dental board record-retention requirements.