The Medical Records Release Form is a critical document used in Indonesian healthcare settings when there is a need to share patient medical information with authorized third parties. This form is essential for compliance with Indonesian healthcare privacy laws, particularly Minister of Health Regulation No. 269/MENKES/PER/III/2008 and the Personal Data Protection Law of 2022. It is used when patients need their medical records transferred to other healthcare providers, insurance companies, legal representatives, or other authorized parties. The form includes detailed patient identification, specific authorization parameters, time limitations, and clear designation of recipients. It serves as both a legal protection mechanism for healthcare providers and a standardized process for patients to exercise their rights regarding their medical information.
Your data doesn't train Genie's AI
You keep IP ownership of your information
Thank you! Your submission has been received!
Oops! Something went wrong while submitting the form.
OR
Let Ƶ's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.
1. Patient Information: Complete identification details of the patient including full name, date of birth, address, and medical record number
2. Healthcare Provider Information: Details of the healthcare facility/provider releasing the records, including name, address, and contact information
3. Recipient Information: Identity and contact details of the person or entity authorized to receive the medical records
4. Records to be Released: Specific description of medical records to be released, including date ranges and types of information
5. Purpose of Disclosure: Statement of the intended use or reason for the release of medical records
6. Duration of Authorization: Specification of how long the authorization remains valid
7. Rights and Notices: Statement of patient's rights including right to revoke authorization and any limitations
8. Signatures: Space for required signatures, dates, and witness attestation if needed
1. Special Categories Authorization: Additional authorization for sensitive information such as mental health records, HIV status, or substance abuse treatment records
2. Electronic Records Transfer: Specific provisions for electronic transfer of records, including format and security measures
3. Third Party Representative: Authorization details when request is made by someone other than the patient (e.g., legal guardian, power of attorney)
4. Cost Information: Details of any fees associated with the records release, if applicable
5. Re-disclosure Notice: Additional provisions regarding potential re-disclosure of information by the recipient
1. Schedule A - Detailed Record List: Itemized list of specific medical records to be released, including dates and document types
2. Schedule B - Proof of Identity: Requirements and acceptable forms of identification for verification purposes
3. Schedule C - Fee Schedule: Detailed breakdown of applicable fees for different types of record requests and processing methods
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Insurance
Legal Services
Education
Employment Services
Sports and Athletics
Government Services
Pharmaceuticals
Medical Research
Occupational Health
Relevant Teams
Medical Records
Compliance
Legal
Administrative Services
Patient Services
Information Management
Privacy and Data Protection
Clinical Operations
Quality Assurance
Healthcare Operations
Relevant Roles
Medical Records Administrator
Healthcare Facility Manager
Compliance Officer
Medical Secretary
Healthcare Provider
Legal Counsel
Privacy Officer
Insurance Claims Processor
Human Resources Manager
Occupational Health Officer
Clinical Research Coordinator
Medical Office Administrator
Find the exact document you need
Title And Lien Release
An Indonesian law-governed document that releases security interests over property and confirms clear title transfer, subject to local property and security regulations.
Download
Medical Work Release Form
An Indonesian-compliant document that certifies an employee's medical fitness to return to work, including any necessary workplace accommodations or restrictions.
Download
Online Release Form
An Indonesian law-compliant electronic release form for obtaining digital consents and liability waivers.
Download
Authorization To Release Employee Information Form
Indonesian-compliant authorization form for releasing employee information to third parties, aligned with PDP Law requirements.
Download
Motor Vehicle Record Disclosure And Release Form
An Indonesian legal form authorizing the release of motor vehicle records in compliance with local transportation and privacy laws.
Download
Consent Form For Release Of Information
An Indonesian law-compliant consent form for authorizing the collection, processing, and sharing of personal information under the PDP Law.
Download
Tenant Release Form
An Indonesian law-compliant document that formally terminates a lease agreement and releases both landlord and tenant from future rental obligations.
Download
Patient Release Form
An Indonesian healthcare document that formally records a patient's discharge from medical care, including discharge instructions and legal acknowledgments, in compliance with Indonesian healthcare regulations.
Download
Promissory Note Release
An Indonesian law-governed document that formally releases and discharges obligations under a promissory note, providing legal evidence of debt satisfaction.
Download
Minor Release Form
An Indonesian law-compliant document providing parental/guardian authorization for a minor's participation in activities and use of their likeness.
Download
Medical Photo Consent Form
An Indonesian-compliant consent form for medical photography that documents patient authorization and usage rights while ensuring privacy protection under Indonesian law.
Download
Audio Release Form
An Indonesian law-compliant agreement authorizing the use, reproduction, and distribution of audio recordings, protecting both content creators and users.
Download
Medical Treatment Authorization And Consent Form
An Indonesian-compliant medical consent form authorizing healthcare providers to perform specified medical treatments while documenting informed patient consent.
Download
Release Of Information Form Mental Health
An Indonesian-compliant authorization form for the release of confidential mental health information, following local healthcare and data protection regulations.
Download
Revocation Of Authorization To Disclose Health Information
An Indonesian legal document for revoking previous authorization to disclose health information, complying with national health privacy and data protection laws.
Download
Participant Release Form
An Indonesian law-governed release form establishing participation terms, consent, and liability waivers for events and activities.
Download
Customer Release Form
An Indonesian-law governed release form documenting customer acknowledgment and acceptance of activity/service risks, drafted in compliance with local consumer protection laws.
Download
Landlord Release Form
An Indonesian law-compliant document that mutually releases landlord and tenant from their lease obligations and settles all related matters.
Download
Medical Treatment Release Form
An Indonesian-compliant medical consent form that documents patient approval for treatment and releases healthcare providers from liability for known risks.
Download
Termination Of Account Letter
An Indonesian-compliant formal notice confirming the termination of a banking account relationship, including closure details and required actions.
Download
Gym Disclaimer Form
An Indonesian-law compliant disclaimer form for gym facilities that establishes usage terms and liability waivers while protecting both facility and user interests.
Download
Release Of Information
An Indonesian law-compliant document authorizing the controlled release of specific information between parties, subject to PDP Law requirements.
Download
Photography Consent Form
An Indonesian-compliant consent form for photography usage and rights, addressing data protection and privacy requirements under Indonesian law.
Download
Release Of Liability
An Indonesian law-compliant document where one party waives their right to make legal claims against another party for specified potential damages or losses.
Download
Authorization To Release Confidential Information
An Indonesian law-compliant authorization document for the controlled release of confidential information, adhering to PDP Law requirements.
Download
Patient Information Release Form
An Indonesian-compliant authorization form for the release of patient medical information, meeting local healthcare privacy and data protection requirements.
Download
Participation Waiver Form
An Indonesian law-governed waiver form where participants acknowledge risks and release the organization from liability for specified activities.
Download
Babysitter Medical Consent Form
An Indonesian law-compliant authorization form enabling babysitters to make medical decisions for minors in their care.
Download
Consent To Share Information
An Indonesian law-compliant consent document for authorized information sharing, aligned with the PDP Law requirements.
Download
Release Request Form
An Indonesian-compliant formal document used to request the release of information, documents, or assets, including necessary declarations and commitments from the requesting party.
Download
Personal Release And Consent Form
An Indonesian law-compliant Personal Release and Consent Form for obtaining and documenting authorized consent for personal data use and content release.
Download
New Release Form
An Indonesian law-governed release form documenting the formal waiver of rights, claims, or liabilities between parties, compliant with the Indonesian Civil Code.
Download
Injury Release Form
An Indonesian law-compliant waiver document protecting organizations from liability claims related to voluntary participation in potentially risky activities.
Download
Employee Key Release Form
An Indonesian-compliant form documenting the issuance of company keys/access devices to employees and their associated responsibilities.
Download
Temporary Guardian Medical Release Form
An Indonesian legal document authorizing a temporary guardian to make medical decisions for a minor child when parents/legal guardians are unavailable.
Download
Physical Therapy Release Form
An Indonesian-compliant legal document establishing consent, terms, and conditions for physical therapy services while protecting both healthcare provider and patient interests.
Download
Medical Release Form To Return To Work
An Indonesian-compliant medical clearance form authorizing an employee's return to work after medical leave, including necessary work modifications and healthcare provider certification.
Download
Hospital Release Form
An Indonesian-compliant document formalizing a patient's discharge from hospital care, including medical instructions and administrative clearance.
Download
Driving Record Consent Form
An Indonesian-compliant consent form for accessing and reviewing individual driving records, adhering to local data protection and transportation laws.
Download
Background Release Form
An Indonesian law-compliant authorization form for conducting background checks on individuals, incorporating PDP Law requirements and consent mechanisms.
Download
ұԾ’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; ұԾ’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it
.png)