Dental Records Release Form

When Do You Need a Dental Records Release Form?

Dentists use past dental records to track changes in a patient’s oral health. Moreover, the records should likewise empower another clinician to effortlessly understand a patient’s present status of wellbeing and the idea of any consideration that has been given. The patient or parent of the underage subject needs to help the current dental specialist gain specific information.

People usually ask for a dental records release when they:

• switch to a new dentist and want to transfer their records
• want a second opinion on a treatment plan
• are sent to a specialist, such as an orthodontist or an oral surgeon
• need to send X-rays and treatment notes to an insurance company

The dental specialist must decide on the suitable maintenance periods for the reports, considering that patient records for adults must stay available for a base time of ten years following the last assistance date.

Note that it is a general form, and some other templates exist, such as the Dental X-ray Form.

Dental Records Release Form Details

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How to Fill Out the Dental Records Release Form

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.

1. Patient name, date of birth and SSN. Enter the patient’s full name, date of birth and SSN on the line at the top of page 1. Check that the name matches the patient’s ID.

   

2. Initial the Information and purposes you choose. Initial each choice that applies on page 1: all of the Information, the Information from a stated period (fill in both dates), or the Information about a specific treatment or condition (write it on the Specify line). Data will be kept in the dental department for five years unless you specify otherwise in the special lines “from” and “to.” Then initial the purposes, or initial All of the above.

   

3. Who receives the Information. In the recipient block on page 1, enter the name of the office or other entity, its address, telephone number and e-mail address.

   

4. Date and sign. Read the statements above the signature line. Then write the date on the DATED line and have the patient or legal representative sign on the signature line. Unless indicated in the given lines, the authorization is legitimate for one year from signing the document. If the patient wants to expand the time, they can write about it in the lines given.

   

5. Notary block. The notary block at the bottom of page 2 has blanks for the day, month and year and a line for the Notary Public. Complete it together with the notary after you sign.

   

Common Mistakes to Avoid

Use this short checklist to review the filled-in FormsPal template before you hand it to a dental practice. Each item is easy to fix before the form is sent, and a quick review gives the receiving office a clear request to work from.

• Leaving the initial lines empty for the Information you want released
• Entering a name that differs from the patient’s ID
• Forgetting to date the signature
• Handing over the signed form without keeping a copy

Frequently Asked Questions

These answers cover common questions about the free FormsPal template, from what the form is used for to what to do after you sign. If your question is not listed, the five steps above walk through each part of the form in order.

What is this release form used for?

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.

What does the FormsPal template ask for?

The FormsPal template asks for the patient’s name, date of birth and SSN, the records the patient chooses to release, the purposes and the receiving entity. It ends with a date, a signature and a notary block.

How long does it take to fill out the form?

The details table above lists an average of 11 minutes and 25 fillable fields. Gathering the patient’s details and the receiving office’s address first helps you finish faster.

Can I fill in the PDF on my computer?

Yes. Download the PDF, open it in the FormsPal PDF editor, type the answers into the text fields and print the pages for signing.

What should I do after signing?

Keep a copy for your own files and give the signed form to the office that holds the records.

General information, not legal or tax advice.

Jennifer M. Settles

Author & Attorney

With over 25 years of experience as a business and transactional attorney, Jennifer has mastered the craft of closing highly successful deals for her clients. Through her wide-ranging expertise in commercial contracts, real estate transactions, M&A and corporate law, Jennifer secures results that are second-to-none.