Dental Records Release Form

Dental Records Release Form Template for United States

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"I need a Dental Records Release Form for my practice in California that allows for both electronic and physical record transfers, with specific provisions for X-rays and treatment plans, and must include Spanish language translation options."

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What is a Dental Records Release Form?

The Dental Records Release Form serves as a crucial document in maintaining patient privacy rights while enabling necessary information sharing in the healthcare system. This form is required whenever dental records need to be transferred between providers, shared with insurance companies, or released to other authorized parties. It ensures compliance with HIPAA regulations and state-specific privacy laws, while providing a clear audit trail of record releases. The form must include specific elements required by federal law, including patient identification, description of information to be released, recipient details, and expiration date of the authorization.

What sections should be included in a Dental Records Release Form?

1. Patient Information: Basic identifying information about the patient including name, date of birth, address, and contact details

2. Authorization Statement: Clear statement of authorization to release dental records, including scope of authorization

3. Records Description: Specific description of dental records to be released, including type of records and date range

4. Recipient Information: Details of the person or entity who will receive the records, including name, address, and relationship to patient

5. Duration of Authorization: Time period for which the authorization is valid, including expiration date

6. Patient Rights Statement: Statement outlining patient's rights including right to revoke authorization and receive copies

7. Signature Block: Space for patient or legal representative signature, date, and witness signature if required

What sections are optional to include in a Dental Records Release Form?

1. Purpose of Disclosure: Optional section specifying the reason for releasing records (e.g., continuing care, legal purposes, insurance)

2. Special Records Authorization: Additional authorization section for sensitive information such as HIV, mental health, or substance abuse information

3. Fee Disclosure: Section detailing any costs associated with records release and copying

What schedules should be included in a Dental Records Release Form?

1. State-Specific Addendum: Additional requirements and disclosures specific to state law compliance

2. Fee Schedule: Detailed breakdown of applicable fees for records copying and processing

3. Records Inventory: Detailed itemized list of specific records being released including dates and types

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Medical Emergency

Business Associate

Clauses

Relevant Industries

Healthcare
Insurance
Legal
Education

Relevant Teams

Administrative
Clinical
Compliance
Legal
Records Management

Relevant Roles

Dental Practice Manager
Dentist
Dental Records Coordinator
Compliance Officer
Office Administrator

Find the exact document you need

Vital Records Authorisation Form

A U.S. legal form authorizing the release of vital records while ensuring compliance with federal and state privacy regulations.

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What is a Dental Records Release Form?

What sections should be included in a Dental Records Release Form?

What sections are optional to include in a Dental Records Release Form?

What schedules should be included in a Dental Records Release Form?

Authors

Alex Denne

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