��������Ƶ

The Dental Records Release Form is a critical document used in Saudi Arabian dental practices to facilitate the legal and compliant transfer of patient dental records. This document becomes necessary when patients require their records to be shared with other healthcare providers, insurance companies, or legal representatives. It ensures compliance with Saudi Arabian healthcare regulations, including the Saudi Healthcare Law (Royal Decree No. M/11) and Ministry of Health guidelines on medical records management. The form includes comprehensive patient identification, specific details about requested records, authorization parameters, and necessary legal disclaimers. It provides protection for both the releasing dental practice and the patient by clearly documenting the scope and purpose of the records release while maintaining patient privacy rights under Saudi law.

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