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Dental Release Of Information Form

Dental Release Of Information Form for the United States

Dental Release Of Information Form Template for United States

A Dental Release of Information Form is a legal document used in the United States that authorizes a dental practice to disclose a patient's protected health information to specified recipients. This document complies with HIPAA regulations and state-specific privacy laws, providing a formal mechanism for the secure and authorized transfer of dental records. It includes specific details about what information can be released, to whom, and for what duration, while protecting patient privacy rights.

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What is a Dental Release Of Information Form?

The Dental Release of Information Form is essential for managing protected health information in accordance with U.S. federal and state regulations. This document becomes necessary when patients need their dental records transferred to other providers, insurance companies, or legal representatives. The form ensures compliance with HIPAA requirements and includes crucial elements such as patient identification, specific authorization details, temporal limitations, and proper documentation of consent. It serves as a critical tool for maintaining patient privacy while facilitating necessary information sharing in the dental healthcare ecosystem.

What sections should be included in a Dental Release Of Information Form?

1. Patient Information: Basic identifying information including name, date of birth, and contact details

2. Authorization Statement: Clear statement of authorization to release information

3. Information to be Released: Specific description of what dental records/information will be released

4. Recipient Information: Details of who will receive the information

5. Duration of Authorization: Expiration date or event for the authorization

6. Rights Statement: Statement of patient's rights including right to revoke

7. Signatures: Patient or legal representative signature and date

What sections are optional to include in a Dental Release Of Information Form?

1. Witness Signature: Required in some states for legal verification - use when required by state law or facility policy

2. Specific Restrictions: Any limitations on what information can be shared - use when patient wants to restrict certain information from being released

3. Payment Information: Details about any fees for records - use when facility charges for record copies

What schedules should be included in a Dental Release Of Information Form?

1. State-Specific Addendum: Additional requirements specific to state law

2. Fee Schedule: If applicable, breakdown of charges for copies of records

Authors

Alex Denne

Head of Growth (Open Source Law) @ Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Jurisdiction

United States

Publisher

Ƶ

Document Type

Release of Information Form

Sector

Data Privacy

Cost

Free to use
Clauses




















Industries

HIPAA: Primary federal law governing healthcare privacy, including Privacy Rule requirements, Security Rule requirements, patient rights regarding protected health information (PHI), and requirements for valid authorization

State-Specific Privacy Laws: Individual state requirements including privacy regulations, dental practice acts, and state-specific records retention requirements that may exceed federal standards

42 CFR Part 2: Federal regulations regarding confidentiality of substance use disorder patient records, applicable if dental records contain such information

HITECH Act: Health Information Technology for Economic and Clinical Health Act requirements regarding electronic health records and security breach notification procedures

FTC Red Flags Rule: Federal Trade Commission requirements for identity theft prevention and verification of identity in healthcare settings

Americans with Disabilities Act: Federal requirements for form accessibility and reasonable accommodations for disabled patients

Required Form Elements: Essential components including patient identification, description of information to be released, purpose of disclosure, recipient information, expiration date/event, patient's right to revoke, redisclosure statement, and signature requirements

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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