Patient Information Release Form - Philippines

Patient Information Release Form for Philippines

Patient Information Release Form Template for Philippines

A comprehensive legal document designed for use in the Philippines healthcare system that facilitates the authorized release of patient medical information from one party to another. This form complies with the Philippine Data Privacy Act of 2012 and relevant healthcare regulations, ensuring proper documentation of consent for the transfer of medical records. It includes detailed sections for patient identification, specification of information to be released, intended recipient, purpose of disclosure, and duration of authorization, while incorporating necessary privacy protections and patient rights as required under Philippine law.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

3. Create your document to edit, review or download

Download a Standard Template

Get our Philippines-compliant Patient Information Release Form

4.6 / 5

4.8 / 5

Alternatively: Run an advanced review of an existing
Patient Information Release Form

Let ��Ƶ's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

What is a Patient Information Release Form?

The Patient Information Release Form is a critical document used in Philippine healthcare settings when there is a need to share medical information with third parties while maintaining compliance with privacy laws. This form becomes necessary when patients need their medical records transferred to other healthcare providers, insurance companies, legal representatives, or other authorized parties. It must comply with the Data Privacy Act of 2012 (RA 10173) and relevant Department of Health regulations. The document includes specific provisions for identifying the patient, detailing the scope of information to be released, naming authorized recipients, and specifying the duration of the authorization. It serves as both a legal protection for healthcare providers and a means of ensuring patient privacy rights are respected.

What sections should be included in a Patient Information Release Form?

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

2. Healthcare Provider Information: Details of the healthcare facility/provider currently holding the medical records, including name, address, and contact information

3. Recipient Information: Complete details of the person or entity authorized to receive the medical information, including name, address, contact information, and relationship to patient

4. Information to be Released: Specific description of medical information authorized for release, including date ranges and types of records

5. Purpose of Disclosure: Clear statement of the reason for releasing the medical information

6. Duration of Authorization: Specific time period for which the authorization is valid

7. Patient 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

What sections are optional to include in a Patient Information Release Form?

1. Special Categories of Information: Additional authorization sections for sensitive information like HIV/AIDS status, mental health records, or substance abuse treatment (used when such records may be included)

2. Legal Representative Authorization: Section for cases where someone other than the patient is authorizing the release, including proof of authority (used when applicable)

3. Minor Patient Information: Additional sections for consent requirements when the patient is a minor (used for patients under 18)

4. Re-disclosure Notice: Additional warnings about potential re-disclosure by the recipient (used when sending to non-healthcare entities)

5. Payment Information: Section detailing any fees associated with the release of records (used when applicable fees will be charged)

What schedules should be included in a Patient Information Release Form?

1. Schedule A - Types of Medical Records Checklist: Detailed checklist of specific types of medical records that can be released (e.g., laboratory results, imaging reports, consultation notes)

2. Schedule B - Proof of Identity Requirements: List of acceptable identification documents for patient/representative verification

3. Schedule C - Fee Schedule: Breakdown of applicable fees for different types of record releases, if any

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

Cost

Free to use

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Medical Services

Hospital Administration

Clinical Practice

Medical Insurance

Legal Services

Healthcare Technology

Public Health

Pharmaceutical

Medical Research

Relevant Teams

Medical Records

Compliance

Legal

Patient Relations

Privacy and Data Protection

Quality Assurance

Risk Management

Administrative Services

Medical Information Management

Clinical Documentation

Healthcare Information Systems

Relevant Roles

Medical Director

Hospital Administrator

Compliance Officer

Medical Records Officer

Privacy Officer

Healthcare Facility Manager

Clinical Department Head

Legal Counsel

Data Protection Officer

Patient Relations Manager

Medical Secretary

Healthcare Documentation Specialist

Quality Assurance Manager

Risk Management Officer

Medical Information Officer

Find the exact document you need

No matches found.

Vehicle Release Form From Police Department

An official Philippine National Police document authorizing and recording the release of an impounded vehicle to its verified owner or representative under Philippine law.

��������Ƶ

How Cambridge United Uses ��������Ƶ to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Template

What is a Patient Information Release Form?

What sections should be included in a Patient Information Release Form?

What sections are optional to include in a Patient Information Release Form?

What schedules should be included in a Patient Information Release Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Vehicle Release Form From Police Department

Simple Photo Consent Form

Release Of Personal Information Consent Form

Psychiatric Release Of Information Form

Medical Release Of Liability

Medical Release Information

Photo Release Authorization Form

Return To Work Medical Release Form

Consent For Release

Motor Vehicle Record Disclosure And Release Form

Information Release

Generic Waiver Form

Dental X Ray Release Form

Consent Form For Release Of Information

Caregiver Medical Release Form

Authorization For Release Of Records Form

Authorization For Disclosure

Universal Release Of Information Form

Transcript Release Authorization Form

Release Of Financial Obligation Form

Publicity Consent Form

Patient Release Form

Patient Authorization For Disclosure Of Health Information

Authorization To Release Loan Information Form

Authorization For Release Of Medical Record Information

Release Of Health Information Form

Doctor Release Form To Return To Work

Online Medical Consent Form

Employee Medical Release Form

Consent To Disclose Medical Information

Consent Form To Disclose Medical Information

Release Of Liability Form For Dental Treatment

Authorization To Release Documents

Legal Medical Consent Form

Medical Release Waiver

Counseling Release Form

Student Release Form

Promissory Note Release

Patient Disclosure Authorization Form

Medication Release Form

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Use Cases

Generate Legal Docs Free

��Ƶ

How Cambridge United Uses ��Ƶ to Speed Up Player Signings and Slash Legal Costs

�ұ�Ծ��’s Security Promise