Dental Records Release Form Template

Patients switch dentists and need charts moved. This dental records release form template captures who is requesting the files, where they should go, and a clear signed authorization.

Great for

• Dental offices sending charts to a new practice
• Patients requesting copies for a specialist referral
• A front-desk link instead of a paper HIPAA-style packet

This is a practical authorization for day-to-day transfers, not a full legal memo. Keep your practice privacy notice separate and have counsel review language for your jurisdiction if you need a formal HIPAA authorization.

Ask which records to send so staff do not ship the entire chart by default. A signature field makes the request clearer than a typed name alone.

Questions in this template

1. Patient full name *
   Name
2. Date of birth *
   Date
3. Phone number *
   Phone
4. Email
   Email
5. Releasing dental office name *
   Short text
6. Releasing office address *
   Long text
7. Receiving dental office name *
   Short text
8. Receiving office address or fax / email *
   Long text
9. Which records should be released? *
   Checkboxes Full chart, X-rays and imaging, Treatment plan, Periodontal charting, Billing / insurance history, Other (describe below)
10. Reason for this request *
    Long text
11. I authorize the release of the dental records described above *
    Yes or no
12. Patient or guardian signature *
    Signature
13. Today's date *
    Date