Release Of Health Information Form

Release Of Health Information Form for Philippines

Release Of Health Information Form Template for Philippines

A comprehensive legal document used in the Philippines that authorizes the release of an individual's protected health information from one entity to another. This form complies with the Philippines Data Privacy Act of 2012 and relevant healthcare regulations, ensuring proper documentation of consent for the transfer of medical records. It includes detailed specifications about the information to be released, the purpose of disclosure, and the rights of the patient under Philippine law, while incorporating necessary privacy protections and compliance requirements set forth by the National Privacy Commission and Department of Health.

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What is a Release Of Health Information Form?

The Release of Health Information Form is a crucial document used in the Philippine healthcare system to facilitate the authorized sharing of medical records while maintaining patient privacy and regulatory compliance. This document becomes necessary when medical information needs to be shared between healthcare providers, transferred to insurance companies, or released to other authorized parties. It must comply with the Data Privacy Act of 2012, Department of Health regulations, and other relevant Philippine healthcare laws. The form ensures that patients maintain control over their medical information while providing healthcare providers with clear documentation of authorization for release. It includes specific provisions for sensitive information, duration of authorization, and the scope of information to be shared, protecting both the releasing entity and the patient's rights.

What sections should be included in a Release Of Health Information Form?

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

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

3. Recipient Information: Identity and contact details of the person or entity authorized to receive the medical information

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

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

6. Duration of Authorization: Validity period of the authorization and expiration date

7. Rights and Notices: Statement of patient's rights including right to revoke authorization and any limitations

8. Signatures: Space for patient or legal representative signature, date, and witness signatures if required

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

1. Special Categories of Information: Additional authorization sections for sensitive information like HIV/AIDS test results, mental health records, or substance abuse treatment (required when such records are included)

2. Legal Representative Authorization: Section for cases where someone other than the patient is authorizing the release, including proof of authority (needed for minors or incapacitated patients)

3. Electronic Transmission Authorization: Specific consent for electronic transmission of records, if applicable

4. Re-disclosure Notice: Additional warnings about potential re-disclosure by recipients (particularly important for international transfers)

What schedules should be included in a Release Of Health Information Form?

1. Schedule A - Detailed Record List: Itemized list of specific medical records to be released, with dates and record types

2. Schedule B - Fee Schedule: List of any applicable fees for record copying and transmission

3. Appendix 1 - Patient Rights Summary: Detailed explanation of patient rights regarding medical records under Philippine law

4. Appendix 2 - Revocation Form: Form that can be used to revoke the authorization

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 Release Of Health Information Form?

What sections should be included in a Release Of Health Information Form?

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

What schedules should be included in a Release Of Health Information Form?

Authors

Alex Denne

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