The Orthodontic Records Release Form is a critical document used in Philippine dental practices when patients or authorized parties need access to orthodontic treatment records. This form becomes necessary during scenarios such as changing providers, seeking second opinions, or when records are required for insurance or legal purposes. It ensures compliance with the Data Privacy Act of 2012 and the Philippine Dental Act of 2007, protecting patient confidentiality while facilitating necessary information transfer. The document includes comprehensive details about the specific records being released, authorization parameters, and the intended use of the information, incorporating all necessary elements required by Philippine healthcare privacy laws and professional dental practice standards.

1. Patient Information: Full legal name, date of birth, contact information, and patient ID number of the person whose records are being released

2. Requesting Party Information: Details of the person or entity requesting the records, including full name, relationship to patient, contact information

3. Records Description: Specific description of the orthodontic records being requested (x-rays, photographs, treatment plans, progress notes, etc.)

4. Purpose of Release: Statement describing the intended use of the released records

5. Authorization Statement: Formal authorization statement permitting the release of records, including reference to relevant privacy laws

6. Duration of Authorization: Timeframe for which the authorization is valid

7. Release Method: Specification of how the records will be transferred or released

8. Signatures: Designated spaces for patient/guardian signature, date, and witness signature if required