The Authorization For Release of Medical Information is a critical document used in Indonesian healthcare settings when there is a need to share patient medical information with authorized third parties. This document is essential for maintaining patient privacy while facilitating necessary information sharing in compliance with Indonesian healthcare regulations, particularly Law No. 29 of 2004 on Medical Practice and Minister of Health Regulation No. 269/MENKES/PER/III/2008. It is commonly used when patients need to share their medical records with new healthcare providers, insurance companies, legal representatives, or other authorized parties. The authorization includes specific details about what information can be shared, the duration of the authorization, and the rights of the patient regarding their medical information, ensuring transparent and controlled information sharing while maintaining patient confidentiality.
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1. Patient Information: Full legal name, date of birth, medical record number, address, and contact information of the patient
2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records
3. Recipient Information: Identity and contact information of the person or entity authorized to receive the medical information
4. Scope of Authorization: Specific description of medical information to be released, including date ranges and types of records
5. Purpose of Disclosure: Clear statement of the reason for releasing the medical information
6. Duration of Authorization: Specific period for which the authorization is valid
7. Rights Statement: Declaration of patient's rights including right to revoke authorization and any limitations
8. Signatures: Space for patient or legal representative signature, date, and witness signatures if required
1. Legal Representative Authorization: Additional section when the authorization is signed by someone other than the patient, including proof of authority
2. Specific Restrictions: Section for noting any specific information that should NOT be released or special handling instructions
3. Electronic Transmission Authorization: Additional authorization specifically for electronic transmission of records, if applicable
4. Fee Acknowledgment: Section acknowledging any applicable fees for record copying or transmission
5. Redisclosure Notice: Additional warning about potential redisclosure by the recipient if relevant under Indonesian law
1. Types of Medical Information Checklist: Detailed checklist of specific types of medical information that may be released (e.g., lab results, imaging reports, treatment records)
2. Proof of Identity: Requirements and acceptable forms of identification for verification purposes
3. Fee Schedule: If applicable, detailed breakdown of any fees associated with the release of medical information
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Healthcare
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Education
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Occupational Health
Sports and Athletics
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Relevant Teams
Medical Records
Compliance
Legal
Patient Services
Administrative Services
Health Information Management
Risk Management
Privacy and Data Protection
Clinical Operations
Customer Service
Relevant Roles
Medical Records Manager
Healthcare Administrator
Compliance Officer
Privacy Officer
Legal Counsel
Medical Secretary
Hospital Administrator
Insurance Claims Processor
HR Manager
Occupational Health Officer
Clinical Research Coordinator
Medical Office Manager
Patient Services Coordinator
Healthcare Legal Advisor
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