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Authorization to Release Dental Information Form Template

Streamline Your Dental Records Transfer Process with Ease

Navigating the paperwork for transferring dental records can be frustrating, especially when you need timely service. This Authorization to Release Dental Information Form template is designed to simplify the process for patients, dentists, and insurance companies, ensuring a smooth transfer of essential dental information. You can easily obtain necessary records for new dental providers, facilitate insurance claims, and comply with HIPAA regulations while maintaining patient trust, all through a clear and accessible format. Experience hassle-free documentation by using our live template today.

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Patient full name
Date of birth
Patient phone number
Patient email address
Practice or provider authorized to release information
Provider office phone
Recipient name or organization
Recipient email (for secure email delivery)
Recipient fax (for fax delivery)
Recipient mailing address (for mail delivery)
Recipient type
Self
New dentist or specialist
Primary care physician or healthcare provider
Insurance company
Attorney or legal representative
Family member or caregiver
School or program
Other
Please Specify:
Select the information to be released
If you selected Other, describe the information
Records from (start date)
Records through (end date)
Sensitive categories you authorize to be included (if present)
HIV/AIDS-related information
Sexually transmitted infection information
Substance use disorder treatment records
Mental or behavioral health information
Genetic testing information
None of the above
Purpose of disclosure
Continuing care or second opinion
Transfer of care
Personal records
Insurance or claims
Legal matter
School or work requirement
Other
Please Specify:
If Other, specify the purpose
Preferred delivery method
Secure email
Fax
Mail
In-person pick-up
Patient portal
I consent to electronic transmission (email, fax, portal) and understand there are security risks.
Yes
No
Expiration date (if Specific date was selected)
Authorization expiration
90 days from signature
180 days from signature
One-time disclosure upon fulfillment
Specific date entered below
No expiration permitted by law
I authorize the disclosing provider named above to release my information as described in this form to the recipient named above.
Yes
No
I understand I may revoke this authorization in writing at any time, except to the extent action has already been taken.
Yes
No
I understand that information disclosed may be re-disclosed by the recipient and may no longer be protected by law.
Yes
No
I understand I may be charged reasonable fees for copies and delivery.
Yes
No
Signature of patient or legal representative
Signer full name
Date signed
Signer relationship to patient
Self
Parent
Legal guardian
Power of attorney or personal representative
Spouse or partner
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Patient phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration related to authorization to release dental information form template by FormCreatorAI

When to use this form

Use this authorization when a patient asks you to send charts, X-rays, images, or billing to another provider, insurer, or attorney. Common scenarios include switching dentists, referring to an oral surgeon, moving out of state, or compiling records for a claim or legal review. It protects privacy, defines exactly what to share, and speeds up transfers. If you need to forward a complete packet to a new office, see the Dental records release form. For consent and privacy acknowledgments, keep a signed Dental HIPAA form on file. When carriers request plan details during claim review, your team can also complete the Dental insurance breakdown form.

Must Ask Authorization to Release Dental Information Questions

  1. Whose dental records are being released (full name, date of birth, and patient ID)?

    This confirms the exact patient and prevents mix-ups with similar names. Including date of birth and any patient ID ties the authorization to the correct chart.

  2. To whom should the records be released (person/organization and contact details)?

    This names the authorized recipient and how to reach them, preventing unintended disclosure. Clear contact details speed secure transmission and follow-up questions.

  3. What specific information and date range may be released?

    This limits the release to the minimum necessary and avoids oversharing. A defined date range and record types (X-rays, treatment notes, periodontal charting, billing) tell staff exactly what to prepare.

  4. What is the purpose of the disclosure and when should this authorization expire?

    Stating the purpose supports privacy rules and guides the team on which documents to include. If a claim needs a narrative, note that you will also submit the Dental narrative submission form.

  5. Will you sign and date, and if you are not the patient, what is your legal relationship and authority?

    A signature makes the request valid and time-bound. Stating your relationship (parent, guardian, or POA) shows you have authority to act for the patient.

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