The Dental Records Release Form is a crucial document used in Dutch dental practices and healthcare settings when patients or authorized parties need to request and transfer dental records. This form is essential for compliance with the Dutch Medical Treatment Contracts Act (WGBO), GDPR, and other relevant healthcare regulations in the Netherlands. It is typically used when patients change dental providers, seek second opinions, need records for insurance purposes, or require records for legal proceedings. The form ensures proper documentation of consent, specifies which records are to be released, and maintains a clear audit trail for data protection purposes. It must be completed accurately to facilitate the secure and lawful transfer of sensitive medical information while protecting both the healthcare provider's and patient's interests under Dutch law.
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1. Patient Information: Complete identification details of the patient including full name, date of birth, address, contact information, and patient ID number
2. Requesting Party: Details of the person or entity requesting the records (if different from patient), including their relationship to the patient
3. Records Details: Specific description of which dental records are being requested (e.g., x-rays, treatment history, billing records) and the time period covered
4. Purpose of Release: Statement of the intended use of the records and reason for the request
5. Authorization Statement: Clear statement of authorization for release, including acknowledgment of understanding of rights and implications
6. Duration of Validity: Specification of how long the authorization remains valid
7. Privacy Notice: GDPR-compliant privacy statement explaining how the information will be handled and protected
8. Signature Block: Space for patient (or authorized representative) signature, date, and witness signature if required
1. Legal Representative Authorization: Additional section required when records are requested by someone other than the patient, including proof of authority to act on patient's behalf
2. Minor Patient Details: Additional section required for patients under 16, including parental/guardian consent details
3. Urgent Request Designation: Optional section to indicate if the request is urgent and requires expedited processing
4. Digital Transfer Consent: Additional section when records will be transferred electronically, including specific consent for digital transmission
5. Fee Acknowledgment: Section detailing any applicable fees for records release, if relevant under Dutch healthcare regulations
1. Record Types Checklist: Detailed checklist of all possible dental record types that can be released, allowing for specific selection
2. Patient Rights Information: Summary of patient rights regarding their dental records under Dutch law and GDPR
3. Authorization Verification Form: Form for verifying identity and authority of person requesting records if not the patient
Relevant legal definitions
Patient
Dental Records
Healthcare Provider
Authorized Representative
Legal Guardian
Dental Practice
Treatment History
X-rays
Clinical Notes
Personal Data
Sensitive Medical Information
Release Authorization
Transfer Period
Receiving Party
Data Controller
Medical Professional
Consent
GDPR
WGBO
Record Custodian
Digital Transfer
Treatment Documentation
Patient File
Professional Standards
Dental Records
Healthcare Provider
Authorized Representative
Legal Guardian
Dental Practice
Treatment History
X-rays
Clinical Notes
Personal Data
Sensitive Medical Information
Release Authorization
Transfer Period
Receiving Party
Data Controller
Medical Professional
Consent
GDPR
WGBO
Record Custodian
Digital Transfer
Treatment Documentation
Patient File
Professional Standards
Clauses
Relevant Industries
Healthcare
Dental Care
Medical Services
Insurance
Legal Services
Healthcare Administration
Data Protection
Relevant Teams
Legal
Compliance
Medical Records
Patient Administration
Front Office
Data Protection
Quality Assurance
Patient Services
Practice Management
Relevant Roles
Dentist
Dental Practice Manager
Healthcare Administrator
Medical Records Officer
Privacy Officer
Compliance Manager
Legal Counsel
Data Protection Officer
Patient Services Coordinator
Insurance Coordinator
Healthcare Quality Manager
Practice Administrator
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