The Dental Refund Release Form is a crucial document used in Malaysian dental practices when processing refunds for dental treatments. This document becomes necessary when a patient requests or is entitled to a refund for dental services, whether due to treatment dissatisfaction, overcharging, insurance adjustments, or other valid reasons. The form complies with Malaysian healthcare regulations, including the Private Healthcare Facilities and Services Act 1998 and the Dental Act 2018, while incorporating necessary elements of the Personal Data Protection Act 2010. It serves multiple purposes: documenting the refund transaction, protecting the dental practice from future claims related to the refunded treatment, and ensuring transparency in the refund process. The document typically includes patient details, treatment information, refund amount, and release clauses, making it an essential tool for dental practices in managing financial transactions and patient relations.

1. Patient Information: Full legal name, identification details, contact information, and patient reference number

2. Dental Practice Information: Practice name, registration number, address, and treating dentist's details

3. Treatment Details: Description of dental services provided, dates of service, and original payment amount

4. Refund Amount: Specific amount to be refunded, payment method, and reasoning for the refund

5. Release Statement: Legal statement releasing the dental practice from further claims related to the specified treatment

6. Acknowledgment: Patient's confirmation of understanding and agreement to the terms of the release

7. Execution: Signature blocks for patient and authorized representative of the dental practice