HIPAA authorization records release form

A two-page authorization for releasing confidential dental information. It records the patient’s name, date of birth, and date of authorization, who started the request, and what to release, such as recent years of records, specific dates, or the full record, with options to include or exclude information on substance abuse and HIV. It lists the purpose of the disclosure, who sends and receives the records, when the authorization expires, and the patient’s signature.

Use it whenever a patient asks for records to go to another dentist, a specialist, an insurer, or a family member. The front desk should have it completed and signed before releasing anything, then keep the form with a note of what was sent.