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Dental X Ray Release Form Template
I need a Dental X Ray Release Form Template for my private dental practice in Cardiff, which will be used to transfer patient X-rays to a specialist orthodontist practice, with specific provisions for digital transfer methods and enhanced data security measures.
1. Patient Information: Full name, date of birth, contact details, NHS number of the patient
2. Requesting Entity Details: Name and contact information of the requesting dental practice or healthcare provider
3. X-Ray Details: Date of X-rays, type of X-rays, reason for release
4. Consent Statement: Clear statement of consent for release of X-rays including data protection notices and GDPR compliance
5. Signatures: Space for patient signature, date, and witness signature if required
1. Third Party Authorization: Additional section when X-rays are to be released to someone other than the patient
2. Time Limitation: Section specifying if the release authorization is only valid for a specific period
3. Special Instructions: Section for any specific handling or delivery instructions
4. Capacity Assessment: Section required when dealing with patients who may lack capacity under the Mental Capacity Act 2005
1. Identity Verification Documents: Schedule for attaching copies of required identification documents
2. Previous Consent Forms: Schedule for attaching any relevant previous release forms or permissions
3. Data Protection Notice: Detailed information about data protection rights and GDPR compliance
Authors
Radiographic Records
Patient
Releasing Practice
Receiving Practice
Authorized Representative
Legal Guardian
Consent
Personal Data
Medical Records
Protected Health Information
Release Authorization
Transfer Period
Dental Records
Healthcare Provider
Data Controller
Data Processor
Ionising Radiation
Treatment Records
Confidential Information
Consent
Authorization
Data Protection
Confidentiality
Release Scope
Duration
Transfer Method
Recipients
Patient Rights
Security Measures
Liability
Record Accuracy
Revocation Rights
Information Use
Third Party Access
Regulatory Compliance
Medical Records
Signatures
Verification
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