Records Request Letter for a Second Opinion
Copy the letter below into an email or print it, fill in the blanks, sign it, and send it to the office that made your treatment plan. It contains what the federal privacy rule asks for, so the office can send your records straight to Austin Periodontal Associates.
The Letter
To: [name of the dental office]
I am requesting copies of my dental records, to be sent directly to the office named below. This is my written, signed request under the HIPAA privacy rule, 45 CFR 164.524.
Patient name: ____________________ Date of birth: ____________________ Phone: ____________________
Please send:
- all radiographs (X-rays) from the past three years, as digital image files
- any cone-beam CT (3D) scan, as DICOM files
- my most recent periodontal chart (pocket depths and bleeding)
- my current treatment plan and the itemized estimate, with procedure codes
- any intraoral photographs
Send them to: Austin Periodontal Associates 7800 N Mopac Expy, Suite 310, Austin, TX 78759 Email: sarah@austinperiodontal.com · Phone: (512) 346-6097
Electronic copies by email are preferred.
Signature: ____________________ Date: ____________________
How to Send It
- Fill in the office name, your details, and anything you want added or removed from the list.
- Sign and date it. A typed name in an email you send from your own address is accepted by most offices; a signed printed copy is accepted by all.
- Send it to the office that made your plan, by email or in person, and copy sarah@austinperiodontal.com so the office here knows to expect the records.
- Book the visit. Request a second opinion or call (512) 346-6097. You do not need to wait for the records to arrive before booking.
Getting a second opinion explains what the visit involves and what you leave with.
Frequently Asked Questions
How long does the office have to send my records?
Under the HIPAA privacy rule (45 CFR 164.524), an office must act on a request for copies within 30 days, with one extension of up to 30 more days if it explains the delay in writing. In practice most dental offices email digital X-rays within a day or two.
Can the office charge me for copies?
It may charge a reasonable, cost-based fee limited to the cost of copying, supplies and postage. Many offices send digital X-rays by email at no charge, and the American Dental Association's code of ethics asks dentists to furnish records gratuitously or for nominal cost.
Do I need to give a reason?
No. The records belong to you, and you do not have to say why you want them.