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AUTHORIZATION AND RELEASE OF DENTAL RECORDS Name: ___Date of Birth: ___ SSN: ___For purposes of the Health Insurance Portability and Accountability Act of 1996 (Public Law 104191, 110 Stat. 2024)

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How to fill out dental record release form

1. To fill out a dental record release form, follow these steps:
2. Start by entering your personal information, such as your full name, date of birth, and contact details.
3. Provide the name and contact information of your current dentist or dental practice.
4. Specify the purpose of the release, whether it is for transferring your records to a new dentist, for legal or insurance purposes, or for personal reference.
5. Indicate the specific dental records you wish to release, such as X-rays, treatment notes, or lab results.
6. Include any special instructions or restrictions regarding the release of your records.
7. Sign and date the form to confirm your consent and understanding of the release.
8. Make sure to keep a copy of the completed form for your records.

Who needs dental record release form?

1. Anyone who requires their dental records to be shared with another dentist, insurance provider, legal entity, or for personal reference may need a dental record release form.
2. Common situations where a dental record release form is necessary include:
3. - When switching to a new dentist and want to transfer your dental history and treatment information.
4. - When filing an insurance claim and the insurance provider requires access to your dental records.
5. - When involved in a legal matter where your dental records may be relevant as evidence.
6. It is always a good idea to consult with your dentist or dental office to determine if a dental record release form is needed in your specific situation.

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What is dental record release form?

A dental record release form is a legal document used to authorize the transfer of a patient's dental records from one dental practice to another or to a third party.

Who is required to file dental record release form?

Typically, the patient or their legal guardian is required to file the dental record release form.

How to fill out dental record release form?

To fill out a dental record release form, provide the patient's personal information, specify the recipient of the records, state the purpose for the release, and sign and date the form.

What is the purpose of dental record release form?

The purpose of the dental record release form is to obtain patient consent for the sharing of their dental records while ensuring compliance with privacy regulations.

What information must be reported on dental record release form?

The form must include the patient's name, contact information, the recipient's details, the specific records being requested, the purpose of the release, and the patient's signature.