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The Dental Records Release Form is a crucial document used in Philippine dental practices to facilitate the legal and compliant transfer of patient dental records. This form becomes necessary when patients require their records to be shared with other healthcare providers, insurance companies, legal representatives, or for personal records. It must comply with the Data Privacy Act of 2012 (RA 10173) and the Philippine Dental Act of 2007 (RA 9484), ensuring proper protection of sensitive health information while enabling necessary information sharing. The form includes comprehensive patient identification, specific authorization details, record descriptions, and clear consent statements, serving as a legal record of the patient's permission for information release while protecting the interests of all parties involved.

1. Patient Information: Full legal name, date of birth, contact information, and patient identification number of the person whose records are being released

2. Authorizing Party: Details of the person authorizing the release (patient, legal guardian, or authorized representative) including their relationship to the patient if not the patient themselves

3. Recipient Information: Complete details of the individual or entity to whom the dental records will be released, including name, address, contact information, and professional credentials if applicable

4. Records Description: Specific description of dental records to be released, including date ranges and types of records (e.g., x-rays, treatment plans, clinical notes)

5. Purpose of Release: Statement of the specific purpose for which the records are being released

6. Authorization Statement: Formal authorization statement compliant with Philippine privacy laws, including duration of authorization validity

7. Rights and Revocation: Statement of patient's rights including the right to revoke authorization and any limitations

8. Signatures: Signature blocks for all required parties with date fields