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Dental Record Release Form Dental Record Release Template

Dental Record Release Form Dental Record Release Template 2026

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The document is an authorization form for the release of dental records, compliant with the Health Insurance Portability and Accountability Act (HIPAA). It allows patients to specify what dental health information can be disclosed, the purpose of the disclosure, and to whom it should be sent. The patient retains the right to revoke this authorization at any time and acknowledges that signing is voluntary. The form includes sections for personal information, specific authorizations, and a signature line.

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Click ‘Get Form’ to open it in the editor.
Begin by entering your name, date of birth, and Social Security Number in the designated fields at the top of the form.
In the authorization section, initial your choices regarding the information you wish to disclose. You can select 'any and all Information' or specify a time period or treatment condition.
Indicate the purpose for which this information will be released by checking the appropriate boxes, such as insurance, employment, or legal purposes.
Fill in the details of the entity receiving your records, including their name, address, telephone number, and email address.
Review your entries for accuracy. Ensure that you understand your rights regarding revocation and disclosure before signing.
Sign and date the form at the bottom. If required, have it notarized as indicated.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do HIPAA laws apply to dentists?

The dentist owns the physical record of the patient and is the legal guardian of the chart and its complete contents, including radiographs.

Why wont my dentist give me my records?

It is illegal for a dentist to refuse you your records even if you havent paid for your treatments. Its a core tennent of autonomy and your right to have your personal files shared with whomever you want. You can give them an email and they must ethically send it within a reasonable time frame.

What is a HIPAA compliant dental records release form?

A dental records release form is a document that authorizes a health care provider to use or disclose a patients dental records. The form contains details like the types of records allowed for release, how the patients information can be used, and when the authorization expires.

Can a dentist refuse to release medical records?

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives patients the right to request that dental practices covered by the regulation send copies of their records to another person designated by the patient.

How do I fill out a record release form?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.

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Can a dentist just take you off their list?

A dentist can remove you from their patient list by giving 3 months notice in writing. The dentist should leave your teeth and gums in a healthy state unless you have refused any treatment recommended by them. If you are violent or threatening, they can remove you from their patient list right away.

What is a dental release?

Patients typically request access to their dental records for another healthcare provider to review. However, they may file a request for other reasons within their rights. When they submit a release-of-records form, they authorize their current dentist to release the records to a designated person.

Dental Record Release Form Dental Record Release Template 2026

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