The Mental Health Release Form is a critical document used in the Philippine healthcare system to facilitate the authorized sharing of mental health information while ensuring compliance with local regulations, particularly the Mental Health Act (RA 11036) and Data Privacy Act of 2012. This document becomes necessary when mental health information needs to be shared between healthcare providers, insurance companies, or other authorized parties, requiring explicit patient consent. It includes comprehensive details about the specific information to be released, the duration of the authorization, and the rights of the patient regarding their mental health records. The form serves as both a legal protection mechanism for healthcare providers and a means of ensuring patient privacy rights are respected in accordance with Philippine law.
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1. Patient Information: Complete identification details of the patient including name, date of birth, address, and contact information
2. Healthcare Provider Information: Details of the mental health professional, facility, or organization providing the services
3. Nature of Information to be Released: Specific description of what mental health records or information are authorized for release
4. Purpose of Release: Clear statement of why the information is being released and how it will be used
5. Duration of Authorization: Specific timeframe for which the release authorization is valid
6. Rights and Notices: Statement of patient's rights regarding the release, including right to revoke and any limitations
7. Confidentiality Statement: Declaration regarding how the released information will be protected and handled confidentially
8. Signature Block: Space for patient (or legal representative) signature, date, and witness signatures if required
1. Legal Representative Authorization: Required when someone other than the patient is authorizing the release, including proof of authority
2. Specific Exclusions: Section detailing any specific information that should NOT be released, used when partial release is requested
3. Electronic Records Consent: Additional consent specifically for release of electronic health records, used when applicable
4. Payment Information: Details about any fees associated with the release of records, if applicable
5. Re-disclosure Notice: Additional warning about potential re-disclosure of information, particularly important for sensitive cases
1. Schedule A - Types of Information: Detailed checklist of specific types of mental health information that may be released
2. Schedule B - Authorized Recipients: List of specific individuals or organizations authorized to receive the information
3. Appendix 1 - Patient Rights: Detailed explanation of patient rights regarding their mental health records and information
4. Appendix 2 - Privacy Practices: Summary of privacy practices and protections in accordance with Philippine law
Relevant legal definitions
Protected Health Information
Mental Health Records
Healthcare Provider
Authorized Recipient
Legal Representative
Release Authorization
Treatment Records
Disclosure
Mental Health Professional
Confidential Information
Electronic Health Records
Medical Facility
Patient Rights
Re-disclosure
Revocation
Valid Period
Treatment Summary
Clinical Notes
Diagnostic Information
Therapeutic Records
Mental Health Records
Healthcare Provider
Authorized Recipient
Legal Representative
Release Authorization
Treatment Records
Disclosure
Mental Health Professional
Confidential Information
Electronic Health Records
Medical Facility
Patient Rights
Re-disclosure
Revocation
Valid Period
Treatment Summary
Clinical Notes
Diagnostic Information
Therapeutic Records
Clauses
Relevant Industries
Healthcare
Mental Health Services
Medical Administration
Social Services
Insurance
Education
Legal Services
Human Resources
Occupational Health
Relevant Teams
Legal
Compliance
Medical Records
Mental Health Services
Administrative Services
Human Resources
Privacy and Data Protection
Patient Services
Quality Assurance
Risk Management
Relevant Roles
Mental Health Professional
Psychiatrist
Psychologist
Clinical Social Worker
Healthcare Administrator
Medical Records Officer
Privacy Officer
Compliance Manager
Legal Counsel
Human Resources Manager
Occupational Health Officer
Healthcare Facility Director
Insurance Claims Processor
Medical Secretary
Patient Care Coordinator
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