Patient Release Form

Photographic Release Form

HIPAA requires patient authorization for the release of protected health information, which includes patient photography, for purposes beyond treatment, payment, and health care operations.

Dentists should obtain written authorization before photographing patients for medical education, staff teaching, and/or publicity purposes. Below is a link to download a generic photographic release form for these purposes. As a matter of procedure, this signed form should be placed in the patient’s permanent medical file in your office.

Click this link to download PDF: PHOTO AND TESTIMONIAL RELEASE FORM

Click this link to download a Word Document Version: PHOTO AND TESTIMONIAL RELEASE FORM