The Authorization For Release Of Dental Records is a critical document used in Philippine dental practices when patients need their records transferred to other healthcare providers or released to authorized parties. This document becomes necessary during various scenarios, such as changing dentists, seeking specialist consultations, insurance claims, or legal proceedings. Governed by the Data Privacy Act of 2012 and the Philippine Dental Act of 2007, it ensures patient privacy while facilitating necessary information sharing. The authorization typically remains valid for a specified period and can be revoked by the patient. It must include detailed patient identification, record specifications, recipient information, and clear consent declarations to comply with Philippine healthcare regulations and privacy laws.

1. Patient Information: Full legal name, date of birth, contact information, and patient identification number (if applicable) of the person whose records are to be released

2. Authorizing Party Declaration: Statement confirming the authority to request records (either patient themselves or legal representative/guardian)

3. Dental Provider Information: Name, address, and contact information of the dental practice/provider currently holding the records

4. Recipient Information: Name, address, and contact information of the person or entity to whom the records will be released

5. Records Description: Specific description of dental records to be released, including date range and types of records (e.g., x-rays, treatment plans, clinical notes)

6. Purpose of Disclosure: Statement indicating the reason for releasing the records

7. Duration of Authorization: Specific timeframe for which the authorization is valid

8. Rights and Disclaimers: Statement of patient rights including right to revoke authorization and any implications of releasing records

9. Signatures: Space for patient/authorized person signature, date, and witness signature if required