Treatment Release Form Template for Philippines

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Key Requirements PROMPT example:

Treatment Release Form

"I need a Treatment Release Form for my dental clinic in Manila, Philippines, that covers both routine procedures and complex oral surgeries, with specific sections addressing local anesthesia risks and post-procedure care requirements."

Document background

The Treatment Release Form is a crucial document in Philippine healthcare settings, required whenever a patient undergoes medical procedures or treatments that carry significant risks or require specific informed consent. It serves multiple purposes: documenting the patient's informed consent, protecting healthcare providers from liability for disclosed risks, ensuring compliance with Philippine healthcare regulations, and establishing clear communication about treatment expectations. The form must comply with various Philippine laws, including the Universal Health Care Act, Data Privacy Act, and relevant provisions of the Civil Code. It is particularly important in scenarios involving surgical procedures, experimental treatments, or high-risk medical interventions. The document should be completed before any non-emergency medical treatment begins and maintained as part of the patient's official medical records.

Suggested Sections

1. Parties: Identification of the healthcare provider/facility and patient (including full names, addresses, and contact information)

2. Background: Brief context about the medical condition and proposed treatment

3. Definitions: Key terms used in the document including medical procedures, treatment-specific terminology

4. Consent to Treatment: Explicit statement of consent for the specified medical treatment or procedure

5. Acknowledgment of Risks: Detailed listing of potential risks and complications associated with the treatment

6. Financial Responsibility: Statement regarding payment obligations and insurance coverage

7. Privacy and Data Protection: Consent for collection and use of personal and medical information in compliance with Philippine Data Privacy Act

8. Release of Liability: Waiver of liability for known and explained risks

9. Governing Law: Specification that Philippine law governs the agreement

10. Signature Block: Space for signatures of patient/guardian, healthcare provider, and witnesses

Optional Sections

1. Emergency Contact Authorization: Authorization for emergency contacts to receive information or make decisions, used when patient wants to designate specific individuals

2. Interpreter Certification: Required when the patient's primary language is not English or Filipino

3. Guardian Consent: Required when the patient is a minor or legally incapacitated

4. Photography Consent: Authorization for medical photography, required for certain procedures or teaching purposes

5. Research Participation: Optional consent for use of treatment data in research studies

6. Religious or Cultural Preferences: Documentation of specific religious or cultural requirements affecting treatment

Suggested Schedules

1. Schedule A - Procedure Details: Detailed description of the specific medical procedure or treatment plan

2. Schedule B - Risk Disclosure: Comprehensive list of potential risks, complications, and side effects

3. Schedule C - Post-Treatment Care: Detailed instructions for post-treatment care and follow-up

4. Schedule D - Fee Schedule: Breakdown of treatment costs and payment terms

5. Appendix 1 - Patient Rights: Summary of patient rights under Philippine healthcare laws

6. Appendix 2 - Medical History Form: Patient's relevant medical history and current medications

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

Hospitals

Dental Services

Alternative Medicine

Cosmetic Surgery

Physical Therapy

Mental Health Services

Medical Research

Insurance

Medical Education

Relevant Teams

Legal

Compliance

Medical Records

Patient Relations

Risk Management

Quality Assurance

Clinical Operations

Administration

Insurance Processing

Document Management

Relevant Roles

Medical Director

Hospital Administrator

Physician

Surgeon

Nurse Manager

Legal Counsel

Compliance Officer

Risk Manager

Medical Records Officer

Patient Relations Manager

Healthcare Facility Manager

Quality Assurance Coordinator

Clinical Department Head

Insurance Coordinator

Medical Office Administrator

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Authors

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