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Administering tests, surgeries, and giving medications to patients who are dealing with oral health-related concerns are some of the duties and responsibilities of a dentist. However, in order to provide any type of dental service to a patient, the dentist and his staff must firstly have the dental records of the patient which can only be obtained by receiving an authorization from the patient and his legal guardian. For this, a dental records release form is one of the documents which should be agreed and signed by the patient for him to permit an organization, his dentist, and all other parties who aim to acquire his confidential dental records.

Dental Records Release Form in DOC

What Is a Dental Records Release Form?

A dental records release form is a document which is used to authorize another party in obtaining dental-related records and data of an individual or a dental patient. Aside from professionals who are working in the fields of medicine and dentistry, business companies and educational institutions can also be the recipients or the target subject of the release form especially for determining an individual’s overall health status as a part of his eligibility requirements. Nonetheless, to ensure that the release form is indeed from the patient as well as from his authorized representative and legal guardian, the receiver of the release form must require the person submitting the form to provide a proof of identification of the patient and himself which will aid the receiver in knowing the relationship of the patient and the submitting person or the requestor.

Dental Records Release Information Sheet Form

Varieties of Dental Records Release Forms

Not all documents are created equal especially for obtaining private and confidential pieces of information about a particular person. This is why there are different varieties of dental records release forms that dentists use which are stated below:

Dental Patient Records Release Form – This variety is the most common document type that dental service providers use. In the form, the requestor or the provider of the release will be able to state as to whom the records will be sent or given, whether to a doctor, an affiliated dentist, or simply to himself. The address of the records and documentation receiver should be indicated in the form as well along with the phone number of the receiver and the reasons for the release. If the requestor is the person who will be using the records for himself, then he will be required to complete an additional section of the form which collects his signature, initials, date of birth, and even his electronic mailing address.

Dental Patient Records Release Form

Dental Record and Radiograph Release Form – Finding hidden dental issues and even determining the bone loss in a patient’s mouth are two main reasons why a dental radiograph result is useful for dentists. Moreover, in order for a dentist to have the radiograph or the x-ray results of a patient, he must inform his patient about the necessity of a release form. Specifically, in a dental record and radiograph release form, the patient will be able to state the name of his previous dentist who has the results. With the release, the patient’s previous dentist will be permitted and authorized to duplicate the results of the patient’s radiography which will then be sent to the patient’s new dental service provider. The general information of the patient will also be important to be disclosed in the form which is for helping the dentists in identifying whose x-ray result and dental records they will release from their archived documents. Additionally, the date of when the patient’s appointment schedule with his new dentist can also be included in the form which is to inform the previous dentist about the need of the patient to obtain the results and records prior to the day of the scheduled appointment.

Dental Record and Radiograph Release Form

Dental Records Release Authorization Form – In the aforementioned forms, a patient or an individual who is the user of the release form is only required to supply basic details about him and his dentist or the entity who will be the recipient or receiver of his released documents. However, in a dental records release authorization form, the user will be able to enlist what specific data and information he will be limiting the releasing personnel such as the range of information and reports to be released and any type of protected health records. Also, this variety of release form caters the effectivity period of the authorization which is significant for ensuring that the information of the user will not be disclosed, duplicated, nor shared to any party beyond the permitted release authorization period. And if the patient is not the user of the form, then the user must indicate his relationship with the patient whether he is the patient’s guardian, conservator, or the patient’s beneficiary. In addition, the last portion must also be read and informed to the releasing personnel which contains a note and a cautionary statement to be mandated and obeyed by the parties involved in the authorization.

Dental Records Release Authorization Form

Dental Records Release Information Disclosure Form – To protect the confidential information of a patient is the purpose of most documents to ensure that the private details will not be included in the dental records release procedure. However, with this form variety, a patient is allowing the releasing personnel or his previously affiliated dentist and practitioners to release all his health information to the recipient who is requesting for the patient’s records, including those which revolve around matters in relation to HIV test results, cancer diagnosis, and acquired sexually transmitted diseases if the marked record category of the patient includes reports of the patient’s private health information. Nonetheless, to complete the form, the patient or the user must complete the form’s patient information section which will contain the patient’s name, address, phone numbers, social security number, and date of birth. The names of the people or the entities who will be receiving the forms, the types of records to be released, and the purpose of the release are all stated in the form as well.

Dental Records Release Information Disclosure Form

How to Create a Simple Dental Records Release Form

Creating a simple dental records release will be easily done with the help of the steps below:

Step 1: Make a basic header. This should contain the logo of the dental service provider or company on the topmost portion of the form along with their name and the title of the form.

Step 2: Add a patient information section. The patient information section of the form should be able to collect the data of the patient which will be useful for identifying whose dental records is requested to be obtained and duplicated. Some of the information to be gathered in this section includes the patient’s full legal name, the names of the patient’s guardians and authorized representatives, the patient’s social security number, and the patient’s emergency contact information.

Step 3: Allocate a recipient information section. This section is specifically for identifying who is the entity or the other party where the patient’s dental records will be obtained. The name of the patient’s former dental practitioner with the address of his office and the office’s company number is required to be disclosed in this section.

Step 4: Make a checklist for the varieties of dental-related records and reports. The checklist will be for effectively determining what data will be requested to be acquired from the patient’s former dentist. Also, the marked items on the list will allow the patient in securing that only the relevant data will be sent by the former dentist towards his newly affiliated practitioner.

Step 5: Incorporate a release authorization statement. The release statement should also have an accompanying signature block which will be for indicating the approval and the signature of the patient along with the date of when he provided his signature and completed the form.

Dental Records Release Form Sample

Why Is a Dental Records Release Form Important?

Dental records release forms are important due to the following reasons:

• It appoints authorized representatives and identifies the patient. Every individual who is previously a patient of a dentist has the right to obtain his dental records, however, if he is incapacitated, he will have to assign or appoint someone else who will request for a records release. This is the purpose of using the form where the name of the requestor will be stated along with the details of the patient.

• It distinguishes the data to be released from the data to be kept. Some information is only meant to be known by named parties which is why using the release form is important in order to define what information to be given to the requestor.

Aside from the two mentioned importance, the form can also be a tool for counting how many record release requests were received by the dental office which will be beneficial for attaining a survey output. However, regardless of the documents or records have been released, the dental office must still retain the documents in their archives unless it has been years after the transaction of the patient.