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1. Patient Information: Full legal name, date of birth, contact details, and any relevant patient identification numbers
2. Dental Practice Details: Name of the dental practice currently holding the records, including address and contact information
3. Recipient Information: Details of the person or entity to whom the records will be released, including name, address, and contact information
4. Records Description: Specific description of which dental records are to be released (e.g., x-rays, treatment notes, billing records)
5. Purpose of Release: Statement explaining why the records are being released (e.g., continuing care, legal proceedings)
6. Authorization Statement: Clear statement of authorization including the time period for which the authorization is valid
7. Privacy Notice: Statement regarding privacy laws and potential re-disclosure of information
8. Signature Block: Space for patient signature, date, and witness signature if required
1. Urgent Request Indicator: Section to indicate if this is an urgent request requiring expedited processing
2. Special Handling Instructions: Any specific instructions for handling or transmitting the records
3. Cost Authorization: Section addressing any fees associated with the records release and payment authorization
4. Legal Representative Authorization: Additional section when someone other than the patient is authorizing the release
5. Revocation Rights: Optional detailed explanation of the right to revoke the authorization
1. Schedule A - Detailed Record List: Itemized list of specific records being requested, including dates and types of records
2. Schedule B - Transfer Method Details: Specific instructions for the secure transfer of records, including permitted methods and security requirements
3. Appendix 1 - Identity Verification Documents: List of acceptable identification documents required for verification
Dental Records
Personal Information
Health Information
Dental Practice
Patient
Recipient
Release
Transfer
Authorization Period
Healthcare Provider
Treatment Records
X-rays
Diagnostic Images
Clinical Notes
Treatment Plans
Billing Records
Consent
Legal Representative
Urgent Request
Electronic Records
Physical Records
Protected Health Information
Re-disclosure
Revocation
Healthcare
Dental Services
Legal Services
Insurance
Healthcare Administration
Medical Records Management
Compliance and Risk Management
Legal
Compliance
Medical Records
Administration
Patient Services
Risk Management
Information Management
Privacy and Data Protection
Clinical Operations
Dentist
Dental Practice Manager
Healthcare Administrator
Medical Records Officer
Compliance Officer
Legal Counsel
Privacy Officer
Insurance Claims Specialist
Healthcare Risk Manager
Practice Administrator
Dental Specialist
Records Management Coordinator
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Genie’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; Genie’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it


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