Permission To Share Medical Information Form for Philippines

Permission To Share Medical Information Form Template for Philippines

A comprehensive legal document compliant with Philippine healthcare and data privacy laws, particularly the Data Privacy Act of 2012 (RA 10173), that enables patients or their legal representatives to authorize the sharing of their medical information with specified recipients. This form ensures proper documentation of consent for the release of medical records while protecting patient privacy rights and healthcare provider liability. It includes detailed specifications of what information can be shared, the duration of the authorization, and the rights of the patient regarding their medical information.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

3. Create your document to edit, review or download

Download a Standard Template

Get our Philippines-compliant Permission To Share Medical Information Form

4.6 / 5

4.8 / 5

Alternatively: Run an advanced review of an existing
Permission To Share Medical Information Form

Let Genie AI's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

Upload your Doc

What is a Permission To Share Medical Information Form?

The Permission To Share Medical Information Form is a crucial document used in Philippine healthcare settings to facilitate the legal and controlled sharing of patient medical information. This document is required whenever patient medical information needs to be shared with third parties, whether for continuing care, insurance purposes, or other authorized uses. It ensures compliance with the Data Privacy Act of 2012 (RA 10173) and related healthcare regulations while protecting both patient privacy rights and healthcare provider liability. The form is designed to capture specific consent for information sharing, including the scope of information to be shared, the duration of the authorization, and the intended recipients. It's particularly important in cases involving multiple healthcare providers, insurance claims, or when medical records are needed for legal or administrative purposes.

What sections should be included in a Permission To Share Medical Information Form?

1. Patient Information: Full legal name, contact details, date of birth, and medical record number of the patient whose information will be shared

2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical information

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

4. Information to be Shared: Specific description of medical information authorized for release (e.g., complete records, specific test results, treatment records for specific dates)

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

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

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

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

What sections are optional to include in a Permission To Share Medical Information Form?

1. Special Categories of Information: Additional authorization sections for sensitive information such as HIV/AIDS status, mental health records, or substance abuse treatment records

2. Legal Representative Authorization: Section to be included when someone other than the patient is authorizing the release of information, including their relationship to the patient and basis for authority

3. Electronic Transmission Authorization: Specific authorization for electronic sharing of records, including associated risks

4. Re-disclosure Notice: Additional section warning about potential re-disclosure by recipients when relevant under specific circumstances

5. Payment Information: Section detailing any fees associated with the release of information, if applicable

What schedules should be included in a Permission To Share Medical Information Form?

1. Schedule A - Detailed Medical Record Categories: Checklist of specific types of medical information that can be selected for sharing (e.g., laboratory results, imaging reports, consultation notes)

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

3. Schedule C - Patient Rights Information Sheet: Detailed explanation of patient rights under Philippine law regarding medical information sharing

4. Appendix 1 - Revocation Form: Form that can be used by the patient to revoke the authorization in the future

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

Cost

Free to use

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospital Administration

Insurance

Pharmaceuticals

Medical Research

Public Health

Elder Care

Mental Health Services

Rehabilitation Services

Relevant Teams

Medical Records

Compliance

Legal

Patient Relations

Data Protection

Quality Assurance

Healthcare Operations

Administrative Services

Risk Management

Information Management

Relevant Roles

Medical Records Officer

Privacy Officer

Healthcare Administrator

Clinic Manager

Hospital Director

Compliance Officer

Medical Secretary

Healthcare Legal Counsel

Patient Relations Manager

Data Protection Officer

Medical Director

Insurance Coordinator

Clinical Documentation Specialist

Quality Assurance Manager

Healthcare Operations Manager

Find the exact document you need

No matches found.

Vehicle Release Form From Police Department

An official Philippine National Police document authorizing and recording the release of an impounded vehicle to its verified owner or representative under Philippine law.

How Cambridge United Uses Genie AI to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Template

What is a Permission To Share Medical Information Form?

What sections should be included in a Permission To Share Medical Information Form?

What sections are optional to include in a Permission To Share Medical Information Form?

What schedules should be included in a Permission To Share Medical Information Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Vehicle Release Form From Police Department

Simple Photo Consent Form

Release Of Personal Information Consent Form

Psychiatric Release Of Information Form

Medical Release Of Liability

Medical Release Information

Photo Release Authorization Form

Return To Work Medical Release Form

Consent For Release

Motor Vehicle Record Disclosure And Release Form

Information Release

Generic Waiver Form

Dental X Ray Release Form

Consent Form For Release Of Information

Caregiver Medical Release Form

Authorization For Release Of Records Form

Authorization For Disclosure

Universal Release Of Information Form

Transcript Release Authorization Form

Release Of Financial Obligation Form

Publicity Consent Form

Patient Release Form

Patient Authorization For Disclosure Of Health Information

Authorization To Release Loan Information Form

Authorization For Release Of Medical Record Information

Release Of Health Information Form

Doctor Release Form To Return To Work

Online Medical Consent Form

Employee Medical Release Form

Consent To Disclose Medical Information

Consent Form To Disclose Medical Information

Release Of Liability Form For Dental Treatment

Authorization To Release Documents

Legal Medical Consent Form

Medical Release Waiver

Counseling Release Form

Student Release Form

Promissory Note Release

Patient Disclosure Authorization Form

Medication Release Form

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Use Cases

Generate Legal Docs Free