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{{ practice_addr }} · {{ practice_phone }} · [email protected]
Form {{ form_no }} Records Release
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Authorization to Release Dental Records

HIPAA · 45 CFR §164.508
1
Patient InformationThe person whose dental records are being released
Initial
Patient name
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Date of birth
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Chart / account #
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Parent / guardian (if a minor)
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Phone
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2
Where Records GoFrom your dental office, to the receiving practice
Initial
Release FROM
Dental office
{{ from_name }}
Address
{{ from_addr }}
Phone / fax
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Disclose TO
Receiving practice
{{ to_name }}
Address
{{ to_addr }}
Phone / fax
{{ to_phone }}
3
Records to ReleaseCheck each item Brightleaf may send to the orthodontist
Initial
Radiographs / X-raysPanoramic, bitewing, cephalometric
Dental chartingTooth chart, restorations, perio
Treatment historyProcedures, dates, providers
Clinical photographsIntraoral and facial images
Study models / scansImpressions, digital scans
Billing / itemized ledgerStatements and balances
Other (specify):{{ records_other }}
Records dated {{ date_from }}through{{ date_to }} or all records on file
4
Purpose & Expiration
Initial
Reason for release
Orthodontic referral / treatment Second opinion Personal copy Insurance
Notes
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This authorization expires
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on or before {{ expire_date }}, or when the records transfer is complete. If left blank it expires one year from the date signed.
Your rights — please read before signing
  1. You can change your mind. Revoke this authorization any time in writing to Brightleaf Dental. Revoking it stops future releases but does not undo records already sent.
  2. Your care is never conditioned on signing. Brightleaf will not refuse treatment or payment because you choose not to sign this release.
  3. Re-disclosure. Once your records reach the receiving practice, they may no longer be protected by HIPAA and could be shared further by that office.
  4. You get a copy. You are entitled to a copy of this signed form; a photocopy is as valid as the original.
I have read and understand this authorization, and I sign it freely to release the dental records I have marked above to the practice named for the purpose stated.
5
Signature
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Signature — patient or parent/guardian
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Date
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Printed name
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Relationship to patient
If the patient is 18 or older, the patient signs above. For a minor or a patient who cannot sign, a parent, guardian, or personal representative signs and notes their authority.
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