Revocation Of Authorization To Disclose Health Information

Revocation Of Authorization To Disclose Health Information for Indonesia

Revocation Of Authorization To Disclose Health Information Template for Indonesia

A formal legal document used in Indonesia to withdraw previously granted authorization for the disclosure of health information. This document complies with Indonesian health privacy laws, including Law No. 36 of 2009 on Health and Law No. 27 of 2022 on Personal Data Protection. It enables patients or their legal representatives to revoke prior permissions given to healthcare providers for sharing medical information, ensuring their right to control their personal health data. The document includes detailed identification of all parties involved, references to the original authorization, and clear statements of revocation intent, along with acknowledgment of the legal implications of such revocation.

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What is a Revocation Of Authorization To Disclose Health Information?

The Revocation Of Authorization To Disclose Health Information is a crucial document in Indonesia's healthcare privacy framework, designed to protect patient rights and maintain control over sensitive medical information. This document becomes necessary when a patient wishes to withdraw previously granted permission for sharing their health information, whether with other healthcare providers, insurance companies, or third parties. It operates within the context of Indonesian health privacy laws, particularly Law No. 36 of 2009 on Health and Law No. 27 of 2022 on Personal Data Protection. The document ensures compliance with legal requirements while providing a clear mechanism for patients to exercise their rights over their medical information. It's commonly used in situations where circumstances have changed since the original authorization, when treatment has concluded, or when patients simply wish to restrict access to their health information.

What sections should be included in a Revocation Of Authorization To Disclose Health Information?

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

2. Healthcare Provider Information: Details of the healthcare provider or facility that currently holds the authorization being revoked, including name, address, and contact information

3. Original Authorization Reference: Information about the original authorization being revoked, including its date, scope, and any reference numbers

4. Revocation Statement: Clear and explicit statement revoking the previous authorization for disclosure of health information

5. Effective Date: Specification of when the revocation takes effect

6. Understanding of Consequences: Statement acknowledging that the revocation will not affect any actions taken before the revocation

7. Signature Block: Space for patient or legal representative signature, date, and witness signature if required

What sections are optional to include in a Revocation Of Authorization To Disclose Health Information?

1. Legal Representative Authorization: Required only when someone other than the patient is signing the revocation, including details of their authority to act on patient's behalf

2. Specific Information Limitation: Optional section to specify if the revocation applies only to certain parts of the health information rather than all information covered by the original authorization

3. Emergency Contact Information: Optional section for including emergency contact details, particularly relevant when dealing with sensitive health information

4. Language Certification: Required only when the document is prepared in multiple languages or when the patient's primary language is not Indonesian

What schedules should be included in a Revocation Of Authorization To Disclose Health Information?

1. Copy of Original Authorization: Attached copy of the original authorization being revoked for reference

2. Proof of Identity: Copies of identity documents of the patient or legal representative

3. Legal Representative Documentation: If applicable, documentation proving the legal authority of a representative to act on behalf of the patient

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

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What is a Revocation Of Authorization To Disclose Health Information?

What sections should be included in a Revocation Of Authorization To Disclose Health Information?

What sections are optional to include in a Revocation Of Authorization To Disclose Health Information?

What schedules should be included in a Revocation Of Authorization To Disclose Health Information?

Authors

Alex Denne

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