Authorization For Release Of Medical Record Information Template for Philippines

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Key Requirements PROMPT example:

Authorization For Release Of Medical Record Information

"I need an Authorization For Release Of Medical Record Information for a multi-specialty hospital in Manila, allowing the transfer of patient records to insurance companies, with specific provisions for electronic record transmission and extra privacy safeguards for mental health records."

Document background

The Authorization For Release Of Medical Record Information is a crucial document used in the Philippine healthcare system when medical records need to be transferred between parties. This document is required whenever a patient's medical information needs to be shared with entities other than the original healthcare provider, whether for continued medical care, insurance purposes, legal proceedings, or other legitimate needs. It ensures compliance with the Data Privacy Act of 2012, the Philippine Medical Act, and other relevant healthcare regulations. The authorization form includes specific details about the patient, the requesting party, the scope of information to be released, and the duration of the authorization. This document is particularly important in protecting patient privacy rights while facilitating necessary information sharing in the healthcare system.

Suggested Sections

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

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 entity authorized to receive the medical records

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 for requesting the medical records

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

7. Rights and Notifications: Statement of patient's rights including right to revoke authorization and privacy rights under Philippine law

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

Optional Sections

1. Legal Representative Authorization: Required when someone other than the patient is authorizing the release, including details of their legal authority

2. Specific Restrictions: Used when patient wants to exclude certain information from being released

3. Payment Information: Include when there are fees associated with copying and releasing records

4. Electronic Release Authorization: Additional section when records will be released in electronic format, including specific consent for electronic transmission

5. Translator Certification: Required when the form is completed in a language other than English or Filipino

Suggested Schedules

1. Schedule A - Types of Medical Records: Detailed checklist of specific types of medical records that can be released (e.g., laboratory results, imaging reports, consultation notes)

2. Schedule B - Fee Schedule: If applicable, breakdown of fees for different types of record releases and processing times

3. Appendix 1 - Privacy Notice: Detailed privacy notice in compliance with the Data Privacy Act of 2012

4. Appendix 2 - Patient Rights: Comprehensive explanation of patient rights regarding medical records and privacy

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

Authorization Grant
Consent
Privacy Notice
Data Protection
Information Scope
Duration and Expiration
Rights and Responsibilities
Revocation Rights
Record Transfer Procedure
Confidentiality
Liability
Purpose Limitation
Authentication
Electronic Processing
Fees and Charges
Governing Law
Signatures and Attestation

Relevant Industries

Healthcare

Insurance

Legal Services

Medical Research

Healthcare Technology

Education (Medical Institutions)

Pharmaceutical

Government Healthcare Services

Social Services

Relevant Teams

Medical Records

Legal

Compliance

Privacy and Data Protection

Patient Services

Healthcare Administration

Quality Assurance

Risk Management

Information Management

Clinical Operations

Relevant Roles

Medical Records Officer

Privacy Officer

Healthcare Administrator

Medical Director

Compliance Officer

Legal Counsel

Hospital Administrator

Clinic Manager

Insurance Claims Processor

Healthcare Data Manager

Medical Secretary

Patient Relations Officer

Quality Assurance Manager

Risk Management Officer

Medical Information Officer

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Let's create your Authorization For Release Of Medical Record Information

Authors

Alex Denne

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