Dental Record Release Form
A release that just says "I authorize my records to be sent" doesn't say which records, sent to whom, or for how long that authorization is good, and HIPAA has a specific list of what actually has to be in there for the release to count as valid. Spell out what's being released, to whom, and until when, before the request goes out.
Right now, a records release sometimes gets handled as a phone call or a one-line note, "please send my x-rays to my new dentist," with nothing written down that would actually satisfy HIPAA's specific requirements for a valid authorization. If the office being asked to send records isn't sure the request is valid, it can get delayed or refused outright, which just means a new provider is starting treatment without the patient's history.
Typeform's dental record release form collects what HIPAA actually requires for a valid authorization: a specific description of what's being released, x-rays, treatment notes, full chart, who's authorized to request it, who's receiving it, the purpose, an expiration date or event, and a signed, dated authorization, along with the required language about the patient's right to revoke and the notice that information can lose HIPAA protection once it leaves a covered entity. Conditional logic can adjust which records categories appear based on the reason for release, a new provider transfer, an insurance request, and a legal request each need slightly different framing.
Every release request lands in one signed record instead of a verbal ask or a sticky note on a chart. One thing to get right before building this: dental records are protected health information, and Typeform's standard plans aren't covered by a HIPAA Business Associate Agreement, that's only available on Enterprise or Growth Custom plans. Collecting PHI, patient names tied to health information, through a standard account is a real compliance gap, so confirm you're on a BAA-covered plan, with a signed BAA actually in place, before using this form for anything containing PHI.
A dental record release form is a patient authorization that permits a dental office to disclose specific records, x-rays, treatment notes, chart entries, to a named recipient, for a stated purpose, within a defined time frame, satisfying HIPAA's requirements for a valid release.
HIPAA requires a valid authorization to specifically describe the information being released, name who's authorized to request it and who's receiving it, state the purpose, include an expiration date or event, and carry a signed, dated authorization. A release missing any of these can get rejected by the office being asked to send records, which just delays the patient's care.
Cover the specific elements HIPAA requires, not just a general consent statement:
- A specific description of the records being released
- Who is authorized to request the records
- Who will receive them
- The purpose of the release
- An expiration date or event
- A signed and dated authorization, plus a statement of the patient's right to revoke
Not if it's going to collect protected health information. Typeform only provides a HIPAA Business Associate Agreement on Enterprise or Growth Custom plans, so a dental record release form, which by definition involves PHI, needs to run on a plan covered by a signed BAA. Using a standard plan to collect this kind of information is a real compliance gap, not just a technicality.
Not necessarily. Part of a valid HIPAA authorization is a required statement that information can be redisclosed by the recipient and may no longer be protected by HIPAA once it leaves the original provider, especially if the recipient isn't itself a HIPAA-covered entity. That notice needs to be in the form itself, not assumed.
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