If you would like a copy of your dental record and/or dental x-rays or delegate this right to someone else, please email Dental Records Request with your completed “Authorization to Release/Receive Information” form.

Please complete the instructions below before submitting your request: 

• Sign and date your request
• If the copy of your records is not going directly to you, please include the address or email of the agency or individual that will be receiving your records
• If submitting your request by email, enter in the subject line of your email “Records Request”
• If submitting your request in person to a DHHS dental clinic, please submit this request during regular business hours.  

Once we receive your written request, your records will be emailed or available for pick up 30 days from the date of the request. Photo identification must be presented when picking up dental records in person. You can find copies of our authorization form below:

• Instructions for Authorization (PDF)
• Authorization to Release/Receive Information
  • English (PDF)
  • Spanish (PDF)
• Notice Prohibiting Redisclosure
  • CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION (English PDF)
  • CONSENT FOR THE RELEASE OF CONFIDENTIAL ALCOHOL OR DRUG TREATMENT INFORMATION (Spanish PDF)