Dental Records Release Form

Dental Records Release Form

The dental records release form is a document that is provided by a dental patient or the parent or guardian of the patient if the patient is a minor, or of proper relations, for the purpose of obtaining dental records from another dentist or dental specialist.

This information is necessary for the dentist to have the ability to review the previous records so that they may be informed with regard to continued maintenance and care with regard to the patient’s dental needs.

The patient or parent of the minor patient, will be required to assist the current dentist to acquire certain information. Other information will be optional.

How to Write

Step 1 – Download in Adobe PDF (.pdf).

Step 2 – Patient Information –

  • Patient’s full name
  • Date of Birth in mm/dd/yyyy format

Step 3 – Authorization –

  • On the next line provided, enter the name of the dentist or the dental practice
  • Check all applicable boxes that would indicate exactly what records must be transferred
  • Specify whether or not, the patient will pick up the records in person or if they will have someone pick them up for them
  • If someone besides the patient shall pick up the dental records, enter the name of the individual who shall be authorized to obtain the records – ( Photo Identification will be required at pick up)
  • If the records will be sent, enter the name and address to whom the records must be sent
  • Phone
  • Fax number
  • Email address
  • Information will be sent for dental activity over the past five year only, unless otherwise requested by entering the years from and to in the lines provided
  • Read the statement pertaining to the types of records that will be sent, which is considered “basic” information. If in agreement, check the box at the end of the paragraph

Step 3 – Disclosure of Further Information –

  • Check the boxes in this section, that the patient would also choose to disclose
  • Enter specific records and information on the lines provided
  • If, in fact, there will be information that the patient does not choose to have the previous dentist/dental practice to disclose, specify that information in the line provided

Step 4 – Expiration –

  • Unless otherwise specified in the “From” and “To” lines, the authorization will only be valid for one year from the date of the form
  • If the patient would like to extend the time the dentist may access records from the previous dentist enter the years in the lines provided

Step 5 – Signature –

  • Enter the signature of the patient or legal representative
  • Date of signature in mm/dd/yyyy format
  • If the person providing signature to this authorization is anyone but the patient, check the applicable box indicating the relationship to the patient
  • The patient must read the final statement printed in bold, and enter the name of the previous dental profession who shall release the initial records