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1. Urgent Request Indicator: Optional section to indicate if this is an urgent request requiring expedited processing

2. Payment Authorization: Section for payment details if fees apply for record copying/transfer

3. Special Instructions: Additional instructions for handling or delivering the records

4. Revocation Rights: Statement explaining the right to revoke the authorization and process for doing so

5. Third Party Authorization: Additional section when records are being released to someone other than the patient or another healthcare provider

1. Schedule A - Types of Records: Detailed checklist of specific dental record types that can be requested (e.g., radiographs, clinical notes, models, photographs)

2. Schedule B - Fee Schedule: If applicable, breakdown of any fees associated with copying or transferring different types of records

3. Appendix 1 - Identity Verification Requirements: List of acceptable identification documents required for verification

4. Appendix 2 - Privacy Notice: Detailed privacy notice explaining how the information will be handled and protected