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1. Patient Information: Complete identification details of the patient including full name, date of birth, contact information, and patient ID number
2. Requesting Party Information: Details of the person or entity requesting the records, including their relationship to the patient if not the patient themselves
3. Records Request Details: Specific description of dental records being requested, including date ranges and types of records (x-rays, treatment plans, etc.)
4. Purpose of Disclosure: Statement of the intended use or reason for requesting the dental records
5. Authorization Statement: Formal authorization language permitting the release of specified dental records
6. Duration of Authorization: Specification of how long the authorization remains valid
7. Rights and Notices: Statement of patient rights regarding the release of records and ability to revoke authorization
8. Signatures: Space for required signatures, dates, and witness attestation if needed
1. Guardian Authorization: Additional section required when the patient is a minor or legally incompetent, including guardian details and authority verification
2. Fee Schedule: Optional section detailing any applicable fees for record copying and transmission, if charges apply
3. Emergency Release: Special authorization section for emergency situations requiring expedited release of records
4. Electronic Transfer Authorization: Additional section for authorizing electronic transmission of records, including specific security measures and recipient details
1. Records Checklist: Detailed checklist of specific dental records being requested (e.g., x-rays, treatment notes, payment history)
2. Fee Schedule Appendix: Detailed breakdown of applicable fees for different types of records and transmission methods
3. Identity Verification Documents: List of acceptable identification documents and verification requirements for different types of requestors
Healthcare
Dental Services
Medical Insurance
Legal Services
Healthcare Administration
Medical Records Management
Regulatory Compliance
Administration
Medical Records
Legal
Compliance
Patient Relations
Quality Assurance
Data Protection
Clinical Operations
Insurance Coordination
Dentist
Dental Practice Manager
Healthcare Administrator
Medical Records Officer
Compliance Officer
Legal Counsel
Insurance Coordinator
Patient Relations Manager
Dental Assistant
Practice Administrator
Quality Assurance Manager
Data Protection Officer
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