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Dental Records Release Form Template

Effortlessly Secure Patient Information with This Template

Handling patient records can be a time-consuming hassle, especially when transferring critical dental history. This dental records release form template helps dentists streamline the collection of patient medical records from other healthcare providers. Enjoy seamless compliance, customized design to fit your practice needs, reduced administrative burdens, and faster patient intake processes while ensuring WCAG-aligned accessibility. Explore the live template and simplify your record management today.

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Patient full name
Date of birth
Phone number
Email address
Mailing address
Patient ID or chart number (optional)
If not the patient, state your relationship to the patient
FROM: Provider or organization name holding the records
FROM: Contact person (optional)
FROM: Phone
FROM: Fax
FROM: Email
FROM: Mailing address
TO: Recipient name or organization
TO: Attention to (recipient contact person)
TO: Phone
TO: Fax
TO: Email
TO: Mailing address
I am completing this form as
Patient
Parent or legal guardian
Personal representative
Other
Please Specify:
Select the records to be released
If Other, describe the specific records
Date range start (if applicable)
Date range end (if applicable)
Include sensitive information categories (if applicable)
HIV/AIDS-related information
Mental or behavioral health information
Substance use disorder treatment information
Genetic testing information
Sexually transmitted infection information
None of the above
Purpose of disclosure
Continuity of care or treatment
Referral or second opinion
Insurance or claims
Legal
Personal use
Moving or relocation
School or employment
Other
Please Specify:
Preferred delivery method
Secure email
Fax
Mail
Patient pickup
Patient portal upload
I authorize the release of the records as described above
Yes
No
I understand I may revoke this authorization in writing at any time
Yes
No
I understand that information disclosed may be subject to redisclosure by the recipient
Yes
No
I understand that copy or transfer fees may apply
Yes
No
Expiration date (if 'On the following date' was selected)
Name of person authorizing release (type full name as signature)
Date of signature
Authorization expiration
30 days from signature
90 days from signature
1 year from signature
On the following date (enter below)
No expiration until revoked
Additional notes or instructions
Best way to contact you with questions
Phone
Email
Text message
Mail
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Phone number","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
paper art illustration depicting a dental records release form with pencil and dental related icons

When to use this form

Use this form when you are moving to a new dentist, need a specialist consult, or want copies for your own records. It authorizes your current practice to send x-rays, treatment notes, and billing history to a named recipient. Parents can use it to transfer a child's chart to an orthodontist or school program. It also helps speed up claims; pair it with the Dental insurance verification form to avoid delays. If you plan ongoing sharing beyond a one-time transfer, consider the Authorization to release dental information form. New providers can review your history before your visit and document findings in a Dental exam form. The result: faster intake, fewer repeat x-rays, and safer care.

Must Ask Dental Records Release Questions

  1. What is the patient's full legal name and date of birth?

    These identifiers match the correct chart and prevent mix-ups with similar names. For minors, DOB also helps confirm the right record for a parent or guardian request.

  2. Who should receive the records (recipient name, practice, and contact details)?

    Clear recipient information ensures your files go to the right person without back-and-forth. Include mailing address, phone, and a secure email or fax to speed delivery.

  3. Which records and date range do you want released?

    Specifying items like radiographs, treatment notes, and billing history limits disclosure to what is needed and reduces processing time. If the new office also needs a current status, they can use a Dental health assessment form.

  4. How should we deliver the records (secure email, portal, mail, or pickup)?

    Your preferred method and file format (PDF, JPEG for x-rays) help us send usable files the first time. This avoids delays from failed transfers or unreadable media.

  5. Do you authorize this release and confirm the expiration date, your signature, and your relationship to the patient?

    These details create a valid consent and show who has the authority to request the transfer. An expiration date prevents open-ended sharing and protects your privacy.

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