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The Authorization To Release Medical Information Form is a critical document in Indonesian healthcare administration that facilitates the legal and secure transfer of patient medical information between healthcare providers or to authorized third parties. This document is required whenever patient medical information needs to be shared outside the original healthcare facility, whether for continued medical care, insurance purposes, legal proceedings, or other authorized purposes. The form must comply with Indonesian healthcare privacy laws, including Law No. 29 of 2004 on Medical Practice and related regulations. It contains specific sections for patient identification, detailed description of information to be released, purpose of disclosure, and duration of authorization, ensuring both patient privacy protection and healthcare provider compliance with legal requirements.

1. Patient Information: Complete identification details of the patient including full name, date of birth, medical record number, ID number (NIK), address, and contact information

2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records, including name, address, and contact information

3. Recipient Information: Complete details of the person or organization authorized to receive the medical information, including name, address, contact information, and relationship to patient if applicable

4. Information to be Released: Specific description of medical information authorized for release, including date ranges and types of records

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

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

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

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