Dental Records Release Form for United Arab Emirates

Dental Records Release Form Template for United Arab Emirates

This document is a standardized form used in the United Arab Emirates for authorizing the release and transfer of dental records from one party to another. It complies with UAE Federal Law No. 5 of 2019 (Health Data Law) and related healthcare regulations. The form includes comprehensive sections covering patient information, recipient details, specific records to be released, purpose of release, and necessary authorizations. It incorporates essential privacy protections and data handling requirements specific to UAE healthcare regulations, ensuring proper documentation of consent and maintaining patient confidentiality in accordance with local laws.

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What is a Dental Records Release Form?

The Dental Records Release Form is a critical document used in healthcare settings throughout the United Arab Emirates when patients or authorized representatives need to request the transfer of dental records. This document becomes necessary when patients change dental providers, seek second opinions, move to different emirates or countries, or require their records for insurance or legal purposes. The form ensures compliance with UAE Federal Law No. 5 of 2019 and related healthcare regulations, particularly regarding patient privacy and data protection. It includes detailed sections for patient identification, specific records requested, intended recipient, purpose of release, and proper authorizations. The document serves as both a legal record of consent and a standardized process for managing dental record transfers in accordance with UAE healthcare regulations.

What sections should be included in a Dental Records Release Form?

1. Patient Information: Contains patient's full name, date of birth, contact details, and identification numbers

2. Dental Practice Information: Details of the dental practice including name, address, license number, and contact information

3. Records Being Released: Specific description of dental records being authorized for release, including types of records and date ranges

4. Purpose of Release: Statement indicating the reason for releasing the dental records

5. Recipient Information: Details of the person or entity to whom the records will be released

6. Authorization Statement: Legal statement confirming patient's consent to release records

7. Duration of Authorization: Timeframe for which the authorization remains valid

8. Patient Rights: Statement of patient's rights regarding the release of records and right to revoke authorization

9. Signatures: Space for patient or legal representative signature, date, and witness if required

What sections are optional to include in a Dental Records Release Form?

1. Legal Representative Authorization: Additional section when records are being released by someone other than the patient (guardian, power of attorney, etc.)

2. Fee Schedule: Section detailing any applicable fees for records release, if charging is permitted

3. Urgent Release Request: Additional section for expedited processing requests

4. Third-Party Payment Authorization: Section for cases where a third party will be paying for the records

5. International Transfer Notice: Required when records are being transferred outside the UAE

What schedules should be included in a Dental Records Release Form?

1. Schedule A - Types of Records: Detailed checklist of specific dental record types that can be released (X-rays, treatment plans, clinical notes, etc.)

2. Schedule B - Fee Structure: If applicable, detailed breakdown of charges for different types of records and processing times

3. Appendix 1 - Identity Verification Requirements: List of acceptable identification documents and verification procedures

4. Appendix 2 - Patient Rights Summary: Detailed explanation of patient rights regarding their dental records under UAE law

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Publisher

Genie AI

Document Type

Authorization Form

Cost

Free to use
Relevant Industries

Healthcare

Dental Services

Medical Insurance

Healthcare Technology

Medical Records Management

Relevant Teams

Legal

Compliance

Medical Records

Patient Services

Administration

Clinical Operations

Data Protection

Quality Assurance

Customer Service

Risk Management

Relevant Roles

Dentist

Dental Practice Manager

Healthcare Administrator

Medical Records Officer

Compliance Officer

Data Protection Officer

Healthcare Legal Counsel

Patient Relations Manager

Insurance Coordinator

Clinical Director

Industries
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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