The Dental Records Request Form is essential for managing patient information access in New Zealand dental practices. This document is used when patients, their authorized representatives, or third parties need to obtain copies of dental records, x-rays, treatment histories, or other related documentation. It ensures compliance with the Health Information Privacy Code 2020, Privacy Act 2020, and other relevant New Zealand healthcare regulations. The form includes necessary fields for patient identification, requestor verification, specific record requirements, and privacy acknowledgments. It serves as both a formal request mechanism and a record of authorization, protecting the interests of all parties involved in the information transfer.

1. Form Title and Practice Details: Clear identification of the document as a Dental Records Request Form and the dental practice's details

2. Patient Information: Full name, date of birth, contact details, and patient identification number (if applicable)

3. Requestor Information: Details of the person requesting the records if different from the patient, including their relationship to the patient

4. Records Request Details: Specific information about what records are being requested, including date ranges and types of records

5. Purpose of Request: Field to indicate why the records are being requested

6. Delivery Preferences: How the requestor would like to receive the records (email, mail, in person)

7. Privacy Declaration: Statement acknowledging privacy obligations and consent for release of information

8. Authentication: Signature section, date, and any required identification verification