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1. Patient Information: Full legal name, date of birth, contact information, and patient identification number if applicable
2. Authorizing Party Declaration: Statement confirming the person's authority to authorize release (patient themselves, legal guardian, or authorized representative)
3. Recipient Information: Details of the person/entity to whom the dental information will be released, including name, address, and contact information
4. Information to be Released: Specific description of dental records to be released (e.g., x-rays, treatment history, billing records)
5. Purpose of Release: Statement indicating the reason for releasing the information
6. Duration of Authorization: Time period for which the authorization remains valid
7. Rights and Disclaimers: Statement of patient's rights including right to revoke authorization and any limitations
8. Signatures: Space for patient/authorized person's signature, date, and witness signature if required
1. Previous Dental Provider Information: Include when records are being transferred from a specific previous dental provider
2. Emergency Contact Authorization: Include when permission is being granted to share information with emergency contacts
3. Special Instructions: Include when there are specific handling instructions or restrictions on the information release
4. Electronic Records Authorization: Include when specifically authorizing release of electronic dental records
5. Payment Authorization: Include when there are fees associated with records release that need to be authorized
1. List of Specific Records: Detailed itemization of specific dental records being authorized for release
2. Fee Schedule: If applicable, breakdown of any fees associated with the release of dental records
3. Identity Verification Documents: List of acceptable identification documents required for verification
Healthcare
Dental Services
Medical Records Management
Healthcare Administration
Insurance
Legal Services
Healthcare Technology
Medical Education
Legal
Compliance
Medical Records
Patient Services
Administration
Operations
Data Management
Privacy and Security
Customer Relations
Documentation
Dentist
Dental Practice Manager
Healthcare Administrator
Medical Records Officer
Compliance Officer
Legal Counsel
Insurance Coordinator
Patient Relations Manager
Privacy Officer
Healthcare Data Manager
Dental Assistant
Dental Hygienist
Medical Office Manager
Healthcare Documentation Specialist
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