Dental Records Release Form

The Dental Records Release Form is a document given by a dental patient or the patient’s parent or guardian if they are underage.

This subtype of a medical release form is used to get dental reports from different dental practitioners. The information is vital for a dental specialist to review the past documents, so they are acknowledged to proceed with support and care concerning the patient’s dental requirements. The patient or parent of the underage subject needs to help the current dental specialist gain specific information.

Find out more information about other types of release of liability form in our article.

dental record release form

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When to Use Dental Records Release

Specialists mainly use dental reports to make conclusions by having itemized information about a patient’s changes in oral wellbeing. 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 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

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
Template Preview
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Filling Out the Dental Records Release Form

In case you are struggling with completing the Dental Records Release form, use the instructions below  to ensure the best results:

1. First, download the template using our template-building software.

2. Fill out the patient information section. Enter the full name and date of birth in an appropriate format.
Step 2 to filling out a dental records release form patient info

3. The next step is called “Authorizes.” On the subsequent line, fill out the name of the dental specialist. Check all relevant boxes, clarifying what records must be moved. Specify whether the patient will get the records face-to-face or somebody will get them for them (indicate who will be responsible for sending the records, applying a photo ID).

If the records will be sent, enter the recipient’s name and address, phone, e-mail address, and fax number. Data will be kept in the dental department for five years unless you specify otherwise in the special lines “from” and “to.”
Step 3 to filling out a dental records release template authorizes

4. Declaration of further data is another segment that must be filled out. Check the boxes in this part with information that the patient would decide to unveil. Do not forget to fill out the suitable lines. If there is some data that the patient does not want to have the past dental specialist or dental practice to know, indicate it.
Step 4 to filling out a dental records release sample data unveiling

5. Expiration. 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.
Step 5 to filling out a dental records release example expiration

6. Finally, sign the document. Fill out the signature section of the patient or any other legitimate delegate. Then, date the signature in an appropriate format. If someone else (not the patient) is signing the document, check the relevant box to show that person’s relationship status to the patient. The patient must carefully read the last statement imprinted and write out the full name of the prior dental specialist who will deliver past records.
Step 6 to filling out a blank dental records release form signature

Published: Aug 26, 2022