The Orthodontic Records Release Form serves as a crucial document in dental healthcare settings across the United States. This form is necessary when patients need their orthodontic records transferred to another provider, require copies for insurance purposes, or need access to their medical information. The document ensures HIPAA compliance and includes specific authorizations for different types of records (such as X-rays, photographs, and treatment plans). It protects both the releasing practice and the patient by documenting consent and maintaining a clear chain of custody for sensitive medical information.
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1. Patient Information: Basic identifying information about the patient including name, date of birth, contact details, and patient ID
2. Records Requested: Specific list of orthodontic records being requested including x-rays, photographs, treatment plans, progress notes, and models
3. Authorization Statement: Clear statement of authorization to release records, acknowledging HIPAA requirements and patient rights
4. Recipient Information: Details of where/to whom records should be sent, including name, address, and contact information of the receiving party
5. Duration of Authorization: Time period for which the authorization is valid and expiration date of the authorization
6. Signature Block: Space for patient/guardian signature, date, and witness signature if required
1. Fee Schedule: Details of any applicable fees for records release and payment terms
2. Rush Processing Request: Option for expedited processing including additional fees and expected turnaround time
3. Reason for Request: Space to indicate why records are being requested (e.g., transfer of care, second opinion, legal proceedings)
1. Types of Records Checklist: Detailed checklist of available record types including x-rays, photos, models, treatment plans, and progress notes
2. Fee Schedule Appendix: Detailed breakdown of fees for different types of records and processing options
3. State-Specific Notices: Required notices or disclosures specific to the state's dental practice and medical records laws
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