Healthcare Dental Records Release

Healthcare Dental Records Release

Patient Name:    Date of Birth:    Gender:

Provider Releasing Records

Recipient of Records (Release To)

Recipient Phone:    Fax:    Email:

Records To Be Released

  All dental records, including but not limited to clinical notes, imaging, treatment plans, billing and correspondence
  Clinical progress notes and treatment history
  Radiographs, digital images and cephalometric records
  Intraoral and extraoral photographs
  Treatment plans and operative reports
  Billing statements and insurance correspondence
  Other:

Purpose and Date Range

Purpose of Disclosure (select all that apply):
  Continuing dental care or referral
  Insurance claim / claim management
  Legal / litigation
  Personal use
  Other (explain below)

Release records from:    through:    (If no date range is provided, include all available records)

Method of Delivery

  Mail physical copies to recipient address
  Patient will pick up records in person
  Fax to the number provided above
  Secure electronic transfer (encrypted) to recipient email
  Unencrypted electronic transmission to recipient email (I understand there are risks of interception)

If authorizing unencrypted electronic delivery, check to acknowledge you accept the risk:

Fees and Payment

I understand that the provider may charge a reasonable fee for copying and/or postage in accordance with applicable law. Copies will not be released until fee arrangements are made unless otherwise required by law.

Acknowledgement of potential fees:

Authorization, Revocation and Redisclosure

By signing below, I hereby authorize the release of the dental records described above. I understand this authorization is voluntary and that treatment, payment, enrollment or eligibility for benefits will not be conditioned on signing this form unless allowed by law.

I understand I may revoke this authorization at any time by submitting a written revocation to the releasing provider, except to the extent that action has already been taken in reliance on this authorization. Revocation will not apply to disclosures made prior to receipt of revocation.

I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy regulations.

I acknowledge I have read and understand the statements above and authorize the release as indicated:

HIPAA Privacy Notice Acknowledgment

I have been provided with, or have access to, the provider's Notice of Privacy Practices describing my rights under the Health Insurance Portability and Accountability Act. I understand the uses and disclosures described therein.

Acknowledgement of receipt or availability of privacy notice:

Representative or Guardian (If Applicable)

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