The Dental Records Release Form serves as a crucial document in Indonesian healthcare administration, designed to facilitate the legal and compliant transfer of dental records between authorized parties. This form is essential when patients need their records transferred to other healthcare providers, require copies for insurance purposes, or need to share records for legal proceedings. The document ensures compliance with Indonesian regulations, particularly Law No. 36 of 2009 on Health and Minister of Health Regulation No. 269/MENKES/PER/III/2008, which govern medical records management. It includes comprehensive patient identification, detailed record specifications, and explicit consent provisions, making it suitable for use in both private dental practices and larger healthcare institutions throughout Indonesia.

1. Patient Information: Complete identification details of the patient including full name, date of birth, address, and contact information

2. Requesting Party Details: Information about the person or entity requesting the dental records, including their relationship to the patient if not the patient themselves

3. Dental Practice Information: Details of the dental practice/practitioner releasing the records, including license number and contact information

4. Records Description: Specific description of the dental records being requested, including date ranges and types of records (x-rays, treatment notes, etc.)

5. Purpose of Release: Clear statement of the intended use of the released records

6. Authorization Statement: Explicit consent statement authorizing the release of dental records, referencing relevant Indonesian privacy laws

7. Duration of Authorization: Specification of how long the authorization remains valid

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