About Your Dental Records
The dental record, also referred to as the patient's chart, is the official office document that records all of the treatment done and all patient-related communications that occur in the dental office. State and federal laws or regulations determine how it is handled, how long it is kept and who may have access to the information. The dental record provides for continuity of care for the patient and is critical in the event of a malpractice insurance claim.
Who Should Make Entries in the Record?
Attorneys and doctors debate who should make the entries in the dental record, but state law will determine this in most cases. Keep in mind that the dentist is ultimately responsible for the patient’s chart.
Who Owns Records
Most dental patients assume that since records are about them, they own them. That is not quite true. Dental office generated those records during examination and treatment process, so dentist owns the records, but patient always can get copies. Dentist is the legal guardian of the chart.
However, even though dentist is required to make copies available to a patient, patient could be asked to pay reasonable cost of reproducing those records.
What is Reasonable Cost
The fee should be limited to cost of supplies and labor for copying and postage (if mailed). However, state laws vary widely on this issue and may specify a limit on what can be charged. Federal HIPAA regulations generally preempt state law but state law may have a more prescriptive restriction on fees that can be charged.
Withholding Records
Dentist can not withhold your dental records for any reason what so ever, as long as you pay the cost associated with reproduction of those records.
Sending Records to another Dentist
Due to the confidential nature of the dental record, before Dentist can send out any copies either to the patient, a patient representative and/or another provider, she or he must make sure to have necessary permissions. Under HIPAA, this refers to an “Acknowledgment” form (and perhaps subject to the “minimum necessary standard”), and in some cases, a specific “Authorization” form. Some states may have more strict requirements.
This usually a Release Form from a patient. A simple release form for release of the record to either the patient or another health care provider may be signed by the patient and become a part of the dental record. This release form, signed by the patient, should specify to whom the records are being delivered and identifying the records. Signing such a form is generally not required by HIPAA to send records to another health care provider, but in some states consent is required before releasing
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