X-Ray Release Form
A phone call asking to send X-rays to a new provider isn't an authorization your compliance file can rely on. Collect patient information, the receiving provider's details, and a signed authorization before the images go out, so your front desk isn't scrambling to prove who approved a release.
A patient calls or stops by asking to have their X-rays sent to a new dentist or specialist, and the request often gets handled as a quick note for whoever's at the front desk that day. Images go out without a documented, signed authorization on file, and if anyone ever needs to confirm who approved the release, or that it went to the right provider, there's nothing beyond a sticky note or someone's memory of the call.
Typeform's X-ray release form asks for what your front desk and compliance file need before images go out: patient name and date of birth, which images and dates are being requested, the receiving provider's name and contact information, and a signed authorization. Conditional logic branches from there. A patient requesting their own images for personal use can route to an identity verification question instead of receiving-provider details, and a request tied to a legal or insurance claim can route to the specific authorization language that scenario requires instead of a standard provider-to-provider release. Every request lands in one signed, dated record instead of a note that might not make it into the file.
Connect the form to your practice management system through Zapier, and a request missing a signature or receiving-provider information can get flagged automatically before your team processes it. Ask for it in writing every time, and your practice has a documented authorization on file instead of a phone call nobody wrote down.
An X-ray release form is an online form medical, dental, or imaging practices use to collect a patient's signed authorization before X-ray images are sent to another provider, an attorney, an insurer, or the patient directly. It replaces a verbal request with a documented, signed record.
A phone call gives you no signature, no date, and no record of exactly what was authorized if anyone asks later. A form captures the patient's authorization directly, tied to specific images and a specific recipient, instead of relying on a note that may or may not make it into the file.
Ask for what your practice will actually need to process and document the release:
- Patient name and date of birth
- Which images are being requested, including dates
- Receiving provider's name and contact information, or the patient's own request for personal use
- Purpose of the release
- Signed authorization and date
- Preferred format, digital file, CD, or printed copies
Not necessarily. HIPAA sets specific requirements for what a valid authorization must include and how it must be documented, and those requirements can vary depending on who's requesting the records and why. It's worth having your compliance officer or attorney review your specific form language rather than relying on a generic template as-is.
Yes. Add a file upload question and patients can attach a photo ID in the same submission, no separate email or in-person visit required. Pair it with conditional logic so identity verification only appears when a patient is requesting their own records directly.
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