The Release Of Information Form Mental Health is a critical document used in the Indonesian healthcare system when there is a need to share confidential mental health information with authorized third parties. This document becomes necessary when mental health records need to be transferred between healthcare providers, shared with insurance companies, used in legal proceedings, or accessed by other authorized entities. It ensures compliance with Indonesian legislation, particularly the Mental Health Law No. 18 of 2014 and Personal Data Protection Law No. 27 of 2022. The form includes comprehensive patient information, specific details about the information to be released, the purpose of release, and the duration of authorization. It serves as a safeguard for patient privacy while facilitating necessary information sharing in accordance with Indonesian legal requirements.
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1. Patient Information: Complete identification details of the patient including full name, date of birth, address, and medical record number
2. Healthcare Provider Information: Details of the healthcare facility and/or mental health professional currently holding the records
3. Recipient Information: Complete details of the person or organization to whom the information will be released
4. Information to be Released: Specific description of what mental health information is authorized for release, including date ranges of records
5. Purpose of Release: Clear statement of the reason why the information is being released
6. Duration of Authorization: Specific time period for which the authorization is valid
7. Rights and Notices: Statement of patient rights including right to revoke authorization and any limitations
8. Authorization Statement: Formal declaration of consent and understanding of the release terms
9. Signatures: Space for patient or legal representative signature, date, and witness if required
1. Legal Representative Authorization: Additional section when the authorization is being given by someone other than the patient, including proof of authority
2. Specific Restrictions: Section for noting any specific restrictions on what information can be shared or how it can be used
3. Electronic Disclosure Consent: Additional authorization specifically for electronic transmission of records, when applicable
4. Payment Information: Section detailing any fees associated with the release of information, if applicable
5. Emergency Contact: Contact information for emergencies or urgent matters related to the information release
1. Types of Information Checklist: Detailed checklist of specific types of mental health information that can be released (e.g., diagnostic records, treatment plans, medication records)
2. Verification of Identity: Form for documenting the verification of the identity of the person requesting information
3. Revocation Form: Template form for future revocation of the authorization if needed
4. Fee Schedule: If applicable, detailed breakdown of any fees associated with different types of information release
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Mental Health Services
Insurance
Legal Services
Education
Social Services
Government Services
Employment Services
Pharmaceutical
Relevant Teams
Legal
Compliance
Medical Records
Patient Services
Mental Health Services
Healthcare Administration
Privacy & Data Protection
Risk Management
Quality Assurance
Clinical Operations
Relevant Roles
Mental Health Professional
Psychiatrist
Psychologist
Medical Records Administrator
Healthcare Facility Administrator
Compliance Officer
Legal Counsel
Privacy Officer
Mental Health Nurse
Social Worker
Insurance Claims Processor
Healthcare Operations Manager
Patient Services Coordinator
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