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Mental Health Records Release Form for Philippines

Mental Health Records Release Form Template for Philippines

This document serves as a formal authorization for the release of mental health records in the Philippines, complying with Republic Act No. 11036 (Mental Health Act) and Republic Act No. 10173 (Data Privacy Act). It enables the secure and legal transfer of confidential mental health information between authorized parties while protecting patient privacy rights. The form includes detailed specifications about what information can be released, to whom, for what purpose, and for how long, along with provisions for consent revocation and privacy protection measures.

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What is a Mental Health Records Release Form?

The Mental Health Records Release Form is a crucial document used in the Philippine healthcare system when there is a need to share confidential mental health information with authorized third parties. This form is designed to comply with the requirements of the Philippine Mental Health Act (Republic Act No. 11036) and the Data Privacy Act (Republic Act No. 10173), ensuring proper protection of sensitive health information while facilitating necessary information sharing. It is typically used when mental health records need to be transferred between healthcare providers, shared with insurance companies, or released to other authorized parties. The form includes comprehensive details about the scope of information to be released, duration of authorization, and specific privacy protections, while clearly outlining the rights of the patient regarding their mental health records.

What sections should be included in a Mental Health Records Release Form?

1. Parties and Information: Identifies the patient, healthcare provider/facility releasing the information, and the recipient of the information, including complete contact details and identification numbers

2. Purpose of Disclosure: Clearly states the specific purpose(s) for which the mental health records are being released

3. Scope of Information: Detailed specification of which mental health records are authorized for release, including date ranges and types of information

4. Duration of Authorization: Specifies the time period for which the authorization is valid, including start and end dates

5. Rights and Revocation: Explains the patient's rights regarding the release of information and the process for revoking authorization

6. Privacy Notice: Statement regarding how the information will be protected and potential for redisclosure by receiving party

7. Signatures and Verification: Space for required signatures, dates, and witness verification if needed

What sections are optional to include in a Mental Health Records Release Form?

1. Emergency Contact Authorization: Additional section for authorizing disclosure to emergency contacts, used when patient wants to designate specific individuals who can access information in emergencies

2. Electronic Records Transfer: Specific provisions for electronic transfer of records, used when records will be shared through digital means

3. Minor Patient Provisions: Additional requirements and authorizations when the patient is a minor, including parent/guardian details

4. Substance Use Treatment Records: Special provisions for release of substance use treatment records, which may require additional privacy protections

5. Translation Declaration: Statement confirming that the form has been explained in a language understood by the patient, used when patient's primary language is not English or Filipino

What schedules should be included in a Mental Health Records Release Form?

1. Schedule A - Detailed Record Description: Comprehensive list of specific mental health records and information types covered by the release authorization

2. Schedule B - Authorized Recipients List: Detailed list of all authorized recipients and their contact information, used when multiple parties are authorized to receive information

3. Appendix 1 - Patient Rights Summary: Summary of patient rights regarding mental health records under Philippine law

4. Appendix 2 - Privacy Protection Guidelines: Detailed information about how the released records will be protected and handled by the receiving party

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

Jurisdiction

Philippines

Publisher

Ƶ

Cost

Free to use
Relevant legal definitions

























Clauses




















Relevant Industries

Healthcare

Mental Health Services

Medical Insurance

Legal Services

Social Services

Education

Healthcare Technology

Public Health

Corporate Wellness

Relevant Teams

Legal

Compliance

Medical Records

Mental Health Services

Patient Services

Healthcare Administration

Privacy and Data Protection

Clinical Documentation

Quality Assurance

Risk Management

Relevant Roles

Mental Health Professional

Psychiatrist

Psychologist

Clinical Social Worker

Medical Records Officer

Healthcare Administrator

Privacy Officer

Compliance Manager

Mental Health Nurse

Medical Director

Insurance Claims Processor

Healthcare Legal Counsel

Patient Relations Manager

Clinical Documentation Specialist

Healthcare Operations Manager

Industries





Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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