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Patient Record Request Form for Saudi Arabia

Patient Record Request Form Template for Saudi Arabia

A standardized form used in Saudi Arabian healthcare facilities for requesting access to patient medical records, designed in compliance with Saudi healthcare regulations, including the Law of Healthcare Professions and Personal Data Protection Law. This document facilitates the formal process of requesting, processing, and releasing medical records while ensuring patient privacy, proper authorization, and compliance with local healthcare information management requirements. It includes comprehensive sections for patient identification, request specifications, consent documentation, and verification procedures.

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What is a Patient Record Request Form?

The Patient Record Request Form serves as an essential document in Saudi Arabian healthcare facilities, enabling patients or their authorized representatives to formally request access to medical records. This form is designed to comply with Saudi Arabia's healthcare regulations, including the Law of Healthcare Professions and Ministry of Health policies on medical records management. It is used when patients need copies of their medical records for various purposes such as continuing care, insurance claims, or legal proceedings. The form captures crucial information including patient identification details, specific records requested, purpose of the request, and necessary authorizations. It includes provisions for identity verification and consent documentation, ensuring proper handling of sensitive medical information while maintaining patient privacy and data protection standards in accordance with Saudi law.

What sections should be included in a Patient Record Request Form?

1. Patient Information: Essential demographic details including full name (in Arabic and English), national ID/Iqama number, date of birth, contact information, and medical record number

2. Request Details: Specific information about the medical records being requested, including date range, type of records, and purpose of request

3. Identity Verification: Requirements for proving identity, including acceptable forms of government-issued ID and verification process

4. Consent Declaration: Patient's explicit consent for release of medical records, with signature and date

5. Processing Information: Details about processing timeframes, fees (if applicable), and preferred method of record delivery

6. Healthcare Facility Information: Details of the facility/facilities from which records are being requested

What sections are optional to include in a Patient Record Request Form?

1. Third Party Authorization: To be included when someone other than the patient is requesting records, including legal guardian, power of attorney, or other authorized representative

2. Urgent Request: Additional section for expedited processing requests, requiring justification and supporting documentation

3. International Transfer: Special considerations and additional requirements when records are being sent outside Saudi Arabia

4. Deceased Patient: Special requirements and documentation needed when requesting records of a deceased patient

5. Record Amendment Request: Section for requesting corrections or amendments to existing medical records

What schedules should be included in a Patient Record Request Form?

1. Appendix A - Required Documentation Checklist: List of required supporting documents for different types of requests

2. Appendix B - Privacy Notice: Detailed information about how the patient's information will be handled and protected

3. Appendix C - Fee Schedule: Breakdown of applicable fees for different types of record requests and processing times

4. Appendix D - Acceptable Forms of ID: Comprehensive list of acceptable identification documents for Saudi nationals and residents

5. Appendix E - Authorization Forms: Template forms for third-party authorization and special circumstances

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

Saudi Arabia

Publisher

Ƶ

Cost

Free to use
Relevant legal definitions






























Clauses




















Relevant Industries

Healthcare

Medical Services

Hospital Administration

Clinical Services

Legal Services

Healthcare Information Management

Data Protection

Medical Insurance

Public Health

Relevant Teams

Medical Records

Patient Services

Legal Affairs

Compliance

Health Information Management

Quality Assurance

Patient Relations

Administrative Services

Data Protection

Clinical Documentation

Relevant Roles

Medical Records Officer

Health Information Manager

Compliance Officer

Healthcare Administrator

Patient Services Coordinator

Medical Secretary

Legal Affairs Specialist

Data Protection Officer

Quality Assurance Manager

Healthcare Facility Director

Patient Relations Manager

Clinical Documentation Specialist

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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