Authorization To Release Medical Information Form Template for Indonesia

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Key Requirements PROMPT example:

Authorization To Release Medical Information Form

"I need an Authorization To Release Medical Information Form under Indonesian law for transferring complete medical records from Jakarta General Hospital to a specialist clinic in Bali, with additional provisions for electronic transmission and extra confidentiality measures for mental health records."

Document background

The Authorization To Release Medical Information Form is a critical document in Indonesian healthcare administration that facilitates the legal and secure transfer of patient medical information between healthcare providers or to authorized third parties. This document is required whenever patient medical information needs to be shared outside the original healthcare facility, whether for continued medical care, insurance purposes, legal proceedings, or other authorized purposes. The form must comply with Indonesian healthcare privacy laws, including Law No. 29 of 2004 on Medical Practice and related regulations. It contains specific sections for patient identification, detailed description of information to be released, purpose of disclosure, and duration of authorization, ensuring both patient privacy protection and healthcare provider compliance with legal requirements.

Suggested Sections

1. Patient Information: Complete identification details of the patient including full name, date of birth, medical record number, ID number (NIK), address, and contact information

2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records, including name, address, and contact information

3. Recipient Information: Complete details of the person or organization authorized to receive the medical information, including name, address, contact information, and relationship to patient if applicable

4. Information to be Released: Specific description of medical information authorized for release, including date ranges and types of records

5. Purpose of Disclosure: Clear statement of the reason(s) for releasing the medical information

6. Duration of Authorization: Specific time period for which the authorization is valid

7. Rights and Notices: Statement of patient's rights including right to revoke authorization and any limitations

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

Optional Sections

1. Specific Restrictions: Optional section for any specific restrictions on the information to be shared or how it may be used

2. Legal Representative Authorization: To be included when someone other than the patient is authorizing the release, including details of their legal authority to do so

3. Sensitive Information Authorization: Special authorization section for sensitive information such as HIV status, mental health records, or genetic information

4. Re-disclosure Notice: Optional section addressing potential re-disclosure of information by the recipient

5. Electronic Transmission Authorization: Special authorization for electronic transmission of records, if applicable

Suggested Schedules

1. List of Specific Records: Detailed itemization of specific medical records to be released, if extensive

2. Proof of Identity: Copies of required identification documents for patient or legal representative

3. Legal Authority Documentation: Copies of power of attorney or other legal documents establishing authority to act on patient's behalf, if applicable

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospital Administration

Insurance

Legal Services

Pharmaceutical

Clinical Research

Occupational Health

Public Health

Relevant Teams

Medical Records

Compliance

Legal

Patient Services

Operations

Risk Management

Data Protection

Quality Assurance

Administrative Services

Healthcare Information Management

Relevant Roles

Medical Records Administrator

Healthcare Facility Manager

Compliance Officer

Medical Administrator

Privacy Officer

Healthcare Legal Counsel

Clinical Director

Patient Services Coordinator

Medical Information Manager

Healthcare Operations Manager

Records Management Specialist

Data Protection Officer

Hospital Administrator

Practice Manager

Healthcare Risk Manager

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Authors

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