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A dental records release form is signed permission to share records. Also called a HIPAA dental records release, this medical release form lets a new dentist review your history. Patients, parents and guardians sign it when changing dentists; our free PDF template is below.
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HIPAA does not require a dental records release form for every transfer, because 45 CFR 164.506(c)(2) lets a dental office covered by HIPAA disclose records for a provider’s treatment activities without one.
The office can still ask you for signed consent, which 45 CFR 164.506(b)(1) allows.
A release matters most when no other HIPAA permission applies. In that case, 45 CFR 164.508(a)(1) bars a covered office from disclosing the records without a valid authorization.
Patients use it to ask an office to send their records to a new dentist, a specialist or another person or business they name. The receiving dentist can then review earlier treatment and X-rays before planning care.
A valid HIPAA authorization must contain six core elements under 45 CFR 164.508(c)(1): the information, who releases it, who receives it, the purpose, an expiration and a signature with a date.
| Core element | Citation | Where it goes on the FormsPal template |
|---|---|---|
| A specific and meaningful description of the information | 45 CFR 164.508(c)(1)(i) | Step 2: the initial lines, the stated period or the Specify line |
| The person or class of persons authorized to release it | 45 CFR 164.508(c)(1)(ii) | No numbered step below: if the form does not name the office that holds the records, write the office’s name on it before signing |
| The person or class of persons who receive it | 45 CFR 164.508(c)(1)(iii) | Step 3: the recipient block |
| Each purpose; “at the request of the individual” is enough when the patient starts the request and gives no other purpose | 45 CFR 164.508(c)(1)(iv) | Step 2: the purposes you initial |
| An expiration date or an expiration event | 45 CFR 164.508(c)(1)(v) | Step 4: the given lines |
| The patient’s signature and the date; a description of the representative’s authority when a personal representative signs | 45 CFR 164.508(c)(1)(vi) | Step 4: the DATED line and the signature line; a representative writes the description of authority on a line the form gives for it, or beside the signature if it gives none |
An authorization that has not been filled out completely on a required element is not valid under 45 CFR 164.508(b)(2)(ii).
The authorization must also carry three notices under 45 CFR 164.508(c)(2):
Plain language is the last requirement, under 45 CFR 164.508(c)(3). Read the statements above the signature line on the template and compare them with this list.
When a covered office seeks the authorization from you, 45 CFR 164.508(c)(4) requires it to give you a copy of the signed form.
You need a dental records release form when an office asks for your written permission before it sends your records to a new dentist, a specialist or another recipient.
Dentists use past dental records to track changes in a patient’s oral health. A new clinician can then see your present dental health and the care you have already had.
People usually ask for a dental records release when they:
Note that it is a general form, and some other templates exist, such as the Dental X-ray Form.
This form shares information and does not waive a claim against a dentist, even though our site lists it under release of liability forms. Other types of release of liability form are covered in our guide.
The FormsPal dental records release form comes as an Adobe PDF, and this table lists its other names, its fillable fields and its average fill-out time.
| Document Name | Dental Records Release Form |
| Other Names | Dental X-ray Release, HIPAA Dental Records Release |
| Avg. Time to Fill Out | 11 minutes |
| # of Fillable Fields | 25 |
| Available Formats | Adobe PDF |
Fill out the dental records release form by entering the patient’s details, initialing the information and purposes, naming the recipient, then dating and signing it.
These steps follow the free FormsPal template. Download it with our template-building software or from the PDF link at the top of the page, then work through the parts in order. Have the patient’s details and the receiving office’s address on hand before you start.
The screenshots under each step show the FormsPal Dental Records Release template filled with sample entries in blue, so you can see where each answer goes. The names, addresses, dates and amounts are examples only.
A dental records release is an authorization that lets an office send your records to someone else, while a dental records request under 45 CFR 164.524 is how you ask for your own records.
The two can overlap. 45 CFR 164.524(c)(3)(ii) also has an office send a copy directly to a person you name, if your request is in writing, signed and clear about that person and where to send the copy. HHS reported in its 2021 proposed rule, 86 FR 6446, that a federal court in Ciox Health v. Azar limited this right to electronic copies in an electronic health record, so ask the office which form it wants for paper records or X-rays.
The rules for your own copy sit in that section, and they apply to a dental office covered by HIPAA:
Ask the office how it takes requests and what it charges before you send yours.
Check a filled-in dental records release form for empty initial lines, a mismatched name, a missing date and a missing copy before you hand it to a dental practice.
These answers cover revoking a release, how long it lasts, signing for a minor, notarization, state rules, refusing to sign and using the PDF.
Yes, a patient can revoke the authorization at any time in writing under 45 CFR 164.508(b)(5), except to the extent the office has already acted on it.
A second exception covers an authorization obtained as a condition of insurance coverage, when other law gives the insurer the right to contest a claim under the policy or the policy itself, 45 CFR 164.508(b)(5)(ii). A short letter to the office naming the patient and the form’s date puts the revocation in writing.
A dental records release lasts until the expiration date or event written on it, a core element under 45 CFR 164.508(c)(1)(v). Check the form for a printed expiration term; if it has none, write an expiration date or event, as the date and sign step above explains.
A parent or guardian with authority over the minor’s health care decisions signs as the legal representative, and 45 CFR 164.508(c)(1)(vi) requires a description of that authority. When a minor consented to their own care, ask the office who can sign for those records.
The six core elements in 45 CFR 164.508(c)(1) do not include a notary, though the FormsPal template has a notary block. Ask the office that holds the records whether it wants that block completed.
This page covers the federal rule at 45 CFR 164.508 and does not check the wording against any state’s rules on dental records. A lawyer where you live can review the form for your state.
A dental office generally cannot refuse treatment because you decline a HIPAA authorization: 45 CFR 164.508(b)(4) bars a covered office from conditioning treatment on it, with exceptions that include research-related treatment and care given solely to create information for a third party.
That bar names authorizations only. An office’s own consent form falls under 45 CFR 164.506(b)(1), which lets the office obtain consent and states no such bar, so ask the office what happens if you decline that form.
Yes, you can download the free PDF, open it in the FormsPal PDF editor, type the answers into the text fields and print the pages for signing.
General information, not legal or tax advice.
