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The Consent To Release Medical Information Form is a crucial document in Indonesian healthcare settings, designed to comply with Law No. 24 of 2022 on Personal Data Protection (UU PDP), Law No. 36 of 2009 on Health, and related regulations. This document is essential when medical information needs to be shared between healthcare providers, insurance companies, or other authorized parties. It serves as a legal safeguard ensuring patient privacy while facilitating necessary information exchange. The form is typically used in situations ranging from routine medical referrals to insurance claims processing, incorporating specific provisions for electronic data transmission when applicable. It must be completed before any protected health information can be released to third parties, except in emergency situations as defined by Indonesian law.

1. Patient Information: Full identification details of the patient including name, date of birth, address, contact information, and medical record number

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

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

5. Purpose of Disclosure: Statement of the specific purpose(s) for which the medical information will be used

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

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

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