The Medical Records Authorization Form is an essential document in the Philippine healthcare system, designed to protect patient privacy while enabling necessary access to medical information. This form is required whenever a patient's medical records need to be shared with parties other than the primary healthcare provider, whether for continuing care, insurance purposes, legal proceedings, or other legitimate needs. It must comply with the Data Privacy Act of 2012 and various healthcare regulations in the Philippines, including specific provisions for sensitive medical information. The form includes comprehensive patient identification, detailed scope of authorization, recipient information, and clear specifications about the duration and purpose of the authorization. It serves as a legal safeguard for both healthcare providers and patients, ensuring proper documentation of consent for medical information sharing.
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1. Patient Information: Complete identification details of the patient including full name, date of birth, address, contact information, and any relevant patient ID numbers
2. Healthcare Provider Information: Details of the healthcare provider or facility currently holding the medical records, including name, address, and contact information
3. Recipient Information: Information about the person or entity authorized to receive the medical records, including name, address, contact details, and relationship to patient if applicable
4. Scope of Authorization: Specific description of what medical information is authorized for release, including date ranges and types of records
5. Purpose of Disclosure: Clear statement of the reason for requesting the medical records
6. Duration of Authorization: Specification of how long the authorization remains valid, including expiration date or event
7. Rights and Notices: Statement of patient's rights regarding the authorization, including right to revoke and any limitations
8. Signatures and Date: Space for patient or legal representative signature, date, and witness signatures if required
1. Specific Restrictions: Used when patient wants to exclude certain types of information from the authorization (e.g., mental health records, HIV status)
2. Legal Representative Authorization: Required when someone other than the patient is authorizing the release, including space for documentation of authority
3. Minor Patient Provisions: Included when the patient is a minor, specifying parent/guardian authorization requirements
4. Electronic Records Authorization: Added when specifically authorizing release of electronic health records or electronic transmission
5. Fee Schedule: Included when there are applicable fees for record copying or transmission
1. Schedule A - Types of Medical Records: Detailed checklist of specific types of medical records that may be released (e.g., laboratory results, imaging reports, consultation notes)
2. Schedule B - Authorized Recipients List: Used when multiple recipients are authorized to receive the records, listing all authorized parties and their details
3. Appendix 1 - Privacy Notice: Detailed information about how the medical records will be handled and protected, in compliance with the Data Privacy Act
4. Appendix 2 - Revocation Form: Template form for revoking the authorization if needed in the future
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Insurance
Legal Services
Medical Research
Healthcare Administration
Public Health
Education (Medical Institutions)
Pharmaceutical
Clinical Trials
Occupational Health
Relevant Teams
Medical Records
Compliance
Legal Affairs
Patient Services
Quality Assurance
Health Information Management
Privacy and Data Protection
Clinical Administration
Risk Management
Customer Relations
Relevant Roles
Medical Records Officer
Healthcare Administrator
Compliance Officer
Privacy Officer
Medical Director
Hospital Administrator
Legal Counsel
Insurance Claims Processor
Medical Secretary
Clinical Research Coordinator
Healthcare Privacy Specialist
Medical Records Clerk
Patient Relations Manager
Quality Assurance Manager
Health Information Manager
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