Disclosure Of Health Information Form for United Arab Emirates

Disclosure Of Health Information Form Template for United Arab Emirates

A comprehensive legal document designed for use in the United Arab Emirates that facilitates the authorized disclosure of patient health information in compliance with Federal Law No. 2 of 2019 and other relevant UAE healthcare regulations. This form serves as a formal authorization mechanism for healthcare providers to share specific patient medical information with designated recipients, while protecting patient privacy rights and ensuring proper documentation of consent. The document incorporates essential elements required by UAE law, including detailed patient identification, specific scope of information to be disclosed, intended recipients, and duration of authorization.

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What is a Disclosure Of Health Information Form?

The Disclosure of Health Information Form is a critical document used in the United Arab Emirates healthcare system to manage and control the sharing of patient medical information. This form is essential for compliance with UAE Federal Law No. 2 of 2019 (Health Data Law) and related healthcare regulations, which mandate specific requirements for health information privacy and data protection. The document is required whenever patient health information needs to be shared between healthcare providers, with insurance companies, or with other authorized parties. It includes comprehensive details about the scope of information to be shared, recipient authorization, temporal validity, and patient rights. Healthcare providers must ensure this form is properly completed and documented before any protected health information can be disclosed to third parties.

What sections should be included in a Disclosure Of Health Information Form?

1. Patient Information: Essential identifying information about the patient including full name, Emirates ID, date of birth, and contact details

2. Healthcare Provider Details: Information about the healthcare facility/provider requesting the disclosure authorization

3. Purpose of Disclosure: Clear statement of the reason(s) for requesting disclosure of health information

4. Information to be Disclosed: Specific description of what health information is authorized for disclosure, including date ranges

5. Recipient Information: Details of the person(s) or organization(s) authorized to receive the health information

6. Duration of Authorization: Specification of how long the authorization for disclosure remains valid

7. Patient Rights Statement: Clear explanation of the patient's rights regarding the disclosure, including right to revoke

8. Signatures and Date: Space for patient (or legal representative) signature, date, and witness if required

What sections are optional to include in a Disclosure Of Health Information Form?

1. Legal Representative Authorization: Required when someone other than the patient is authorizing the disclosure, including proof of authority

2. Specific Consent for Sensitive Information: Additional authorization section for sensitive medical information like mental health, HIV status, or genetic information

3. Electronic Disclosure Authorization: Specific consent for electronic transmission of health information when applicable

4. Translation Certification: Required when the form is provided in multiple languages or requires translation

5. Emergency Contact Information: Optional section for emergency contact details when relevant to the disclosure purpose

What schedules should be included in a Disclosure Of Health Information Form?

1. Schedule A - Types of Health Information: Detailed checklist of specific types of health information that can be disclosed

2. Schedule B - Authorized Recipients List: Detailed list of all authorized recipients when multiple parties are involved

3. Appendix 1 - Revocation Form: Form for revoking the authorization if the patient chooses to do so

4. Appendix 2 - Privacy Policy Summary: Summary of the healthcare provider's privacy policies and information handling practices

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

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What is a Disclosure Of Health Information Form?

What sections should be included in a Disclosure Of Health Information Form?

What sections are optional to include in a Disclosure Of Health Information Form?

What schedules should be included in a Disclosure Of Health Information Form?

Authors

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