Medical Records Release Authorization Form Template for Saudi Arabia

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Key Requirements PROMPT example:

Medical Records Release Authorization Form

"I need a Medical Records Release Authorization Form for a private hospital in Riyadh that allows the transfer of pediatric patient records to a specialist clinic, with specific provisions for sharing diagnostic imaging and test results from January 2025 to June 2025."

Document background

The Medical Records Release Authorization Form is a critical document used in Saudi Arabian healthcare settings when patient medical information needs to be shared with authorized third parties. This form is essential for maintaining patient privacy rights while facilitating necessary information exchange between healthcare providers, insurance companies, legal representatives, or other authorized recipients. It must comply with Saudi Arabia's healthcare regulations, including the Law of Healthcare Professions 2005, the Personal Data Protection Law (PDPL) 2021, and the Saudi Patient's Bill of Rights. The document becomes necessary in various scenarios such as continuing medical care, insurance claims, legal proceedings, or research purposes, and includes specific provisions for the type of information to be released, duration of authorization, and intended use of the information.

Suggested Sections

1. Patient Information: Essential identifying information including full name, date of birth, medical record number, contact details, and national ID number

2. Healthcare Provider Information: Details of the healthcare facility/provider 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, including name, role/relationship, organization, and contact information

4. Information to be Released: Specific description of medical records to be released, including date ranges and types of information (e.g., consultation notes, test results, imaging reports)

5. Purpose of Disclosure: Clear statement of the reason for releasing the medical records (e.g., continuing care, legal purposes, insurance)

6. Duration of Authorization: Specific timeframe for which the authorization is valid, including expiration date

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

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

Optional Sections

1. Sensitive Information Authorization: Additional authorization for release of sensitive information such as mental health records, genetic testing, or HIV status - used when such records are part of the request

2. Legal Representative Authorization: Required when someone other than the patient is authorizing the release, including proof of authority and relationship to patient

3. Electronic Records Transfer: Specific provisions for electronic transfer of records, including preferred format and security measures - used when digital transfer is requested

4. Translation Declaration: Required when the form is provided in multiple languages, confirming the patient's understanding of the content

5. Research Use Authorization: Additional provisions when records are being released for research purposes, including specific research project details

Suggested Schedules

1. Schedule A - Detailed Record List: Itemized list of specific medical records being requested, with dates and record types

2. Schedule B - Fee Schedule: List of applicable fees for record copying and transmission, if any

3. Appendix 1 - Identity Verification Documents: List of acceptable identification documents and verification requirements

4. Appendix 2 - Revocation Form: Template form for revoking the authorization if needed

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 Insurance

Legal Services

Healthcare Technology

Medical Research

Pharmaceutical

Healthcare Education

Public Health

Relevant Teams

Medical Records

Legal

Compliance

Patient Relations

Health Information Management

Quality Assurance

Risk Management

Administrative Services

Clinical Documentation

Privacy and Security

Relevant Roles

Medical Records Manager

Healthcare Administrator

Compliance Officer

Medical Director

Patient Relations Coordinator

Legal Counsel

Privacy Officer

Health Information Manager

Medical Secretary

Clinical Documentation Specialist

Healthcare Facility Manager

Quality Assurance Manager

Risk Management Officer

Patient Services Coordinator

Medical Records Clerk

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