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Orthodontic Records Release Authorization
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Orthodontic Records Release Authorization

2 pages•14 fields•HIPAA-ready
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Orthodontic Records Release Authorization

Orthodontic Records Release Authorization

Page 1 of 2

Patient Name
Jane Martinez
Date of Birth
03/15/1985
Patient Account Number
Release Records To
Recipient Practice Name
Jane Martinez
Records Requested
Purpose of Release
Select an option...
Authorization Signature
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Submit
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This records release form is specifically designed for orthodontic practices to authorize the transfer of comprehensive treatment documentation to other providers. It covers all types of orthodontic records including diagnostic x-rays, cephalometric films, intraoral and extraoral photographs, study models, treatment plans, progress notes, appliance specifications, and payment history. The form ensures HIPAA compliance while facilitating continuity of care when patients relocate or seek second opinions.

The template streamlines the authorization process with clear identification of what records will be released, to whom, for what purpose, and the timeframe of authorization. It includes options for releasing records to general dentists, other orthodontists, oral surgeons, periodontists, insurance companies, or legal representatives. The form protects practices legally while ensuring patients can access and transfer their treatment information efficiently, particularly important for ongoing orthodontic cases requiring multi-year treatment continuity.

What's included

  • Patient identification information
  • Recipient provider details
  • Specific records to be released
  • X-rays and imaging authorization
  • Photographs and models release
  • Treatment plan documentation
  • Progress notes access
  • Purpose of disclosure
  • Authorization expiration date
  • Patient signature and date

Who uses this template

  • Orthodontic practices
  • Dental specialty offices
  • Oral surgery centers
  • General dentistry practices
  • Pediatric dental offices

All form fields

8 fields across 2 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Patient Account NumberText
Release Records ToText
Recipient Practice NameText
Records RequestedCheckbox
Purpose of ReleaseDropdown
Authorization SignatureE-Signature
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