The Release of Information Form Therapy is a critical document in Indonesian healthcare settings that facilitates the authorized sharing of confidential therapeutic information while maintaining compliance with local data protection and healthcare laws. This document becomes necessary when there is a need to share patient information with other healthcare providers, insurance companies, legal representatives, or other authorized parties. It ensures that sensitive mental health and therapeutic information is handled according to Indonesian regulations, particularly Law No. 27 of 2022 on Personal Data Protection and Law No. 18 of 2014 on Mental Health. The form includes comprehensive details about the scope of information to be shared, timeframes, and specific authorizations, while protecting patient rights and maintaining professional standards in therapeutic practice.
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1. Patient Information: Full identification details of the patient including name, date of birth, address, and contact information as required by Indonesian healthcare regulations
2. Provider Information: Details of the therapeutic service provider/facility currently holding the information, including license numbers and contact details
3. Recipient Information: Complete details of the person(s) or organization(s) authorized to receive the information
4. Information to be Released: Specific description of the therapeutic/medical information to be disclosed, including date ranges and types of records
5. Purpose of Disclosure: Clear statement of the reason(s) for releasing the information
6. Duration of Authorization: Specific timeframe for which the authorization is valid
7. Rights and Notifications: Statement of patient rights under Indonesian law, including right to revoke authorization and any limitations
8. Signatures and Date: Space for patient (or legal representative) signature, date, and witness signatures if required
1. Legal Representative Authorization: Required when someone other than the patient is authorizing the release, including details of their legal authority
2. Specific Restrictions: Optional section for patients to specify any limitations or restrictions on the information to be released
3. Electronic Record Transfer: Additional provisions for electronic transfer of records, if applicable
4. Fee Schedule: Information about any applicable fees for record copying or transfer, if relevant
5. Emergency Contact: Optional section for emergency contact information in case of queries or issues
1. Schedule A - Types of Information Covered: Detailed checklist of specific types of therapeutic records and information that may be released
2. Schedule B - Authorized Recipients List: If multiple recipients are authorized, detailed list with specific permissions for each
3. Appendix 1 - Patient Rights Summary: Detailed explanation of patient rights regarding information release under Indonesian law
4. Appendix 2 - Revocation Form: Form that can be used by the patient to revoke the authorization if needed
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Mental Health
Counseling Services
Psychology
Psychiatry
Social Services
Medical Administration
Healthcare Technology
Insurance
Legal Services
Relevant Teams
Legal
Compliance
Medical Records
Patient Services
Clinical Operations
Privacy and Data Protection
Healthcare Administration
Risk Management
Quality Assurance
Information Technology
Relevant Roles
Therapist
Clinical Psychologist
Psychiatrist
Mental Health Counselor
Healthcare Administrator
Medical Records Officer
Compliance Officer
Privacy Officer
Healthcare Facility Manager
Legal Counsel
Insurance Coordinator
Patient Services Coordinator
Mental Health Practice Manager
Clinical Director
Healthcare Data Protection Officer
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