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Medical Release Form for Indonesia

Medical Release Form Template for Indonesia

A Medical Release Form governed by Indonesian law is a legal document that authorizes healthcare providers to disclose a patient's medical information to specified parties. The document complies with Indonesian healthcare regulations, particularly Law No. 36 of 2009 on Health and related ministerial regulations governing patient privacy and medical records. It includes detailed provisions for information sharing, patient rights, consent requirements, and data protection measures in accordance with Indonesian legal requirements. The form serves as both a protection for healthcare providers and a guarantee of patient rights in the context of medical information disclosure.

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What is a Medical Release Form?

The Medical Release Form is a crucial document in Indonesian healthcare settings, designed to facilitate the authorized sharing of patient medical information while ensuring compliance with Indonesian healthcare regulations and data protection laws. This document becomes necessary when patient medical information needs to be shared with third parties, whether for continuing care, insurance purposes, or other legitimate medical or administrative needs. The form must comply with Law No. 36 of 2009 on Health, ministerial regulations on medical records, and Indonesia's data protection requirements. It includes comprehensive patient identification, specific authorization details, temporal validity, and clear delineation of both rights and responsibilities. The document serves as a legal safeguard for healthcare providers while ensuring patient privacy rights are protected under Indonesian law.

What sections should be included in a Medical Release Form?

1. Patient Information: Complete identification details of the patient including full name, date of birth, ID number (KTP/passport), and contact information

2. Healthcare Provider Information: Details of the healthcare facility and/or medical practitioner authorized to release the information

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

4. Scope of Authorization: Specific description of medical information authorized for release, including time period covered

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

6. Duration of Authorization: Validity period of the authorization, including start and end dates

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

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

What sections are optional to include in a Medical Release Form?

1. Emergency Contact Authorization: Additional authorization for emergency contacts to receive medical information, used when patient wants to designate specific individuals for emergency situations

2. Electronic Communications Consent: Additional consent for sharing information via electronic means, used when digital transmission of records is anticipated

3. Minor Patient provisions: Special provisions for patients under 18, used when the patient is a minor

4. Translation Declaration: Declaration that the form has been explained in a language understood by the patient, used when patient's primary language is not Indonesian

5. Legal Representative Authorization: Additional section for cases where a legal representative is acting on behalf of the patient

What schedules should be included in a Medical Release Form?

1. Schedule A - Types of Medical Information: Detailed checklist of specific medical information types authorized for release (e.g., diagnostic records, lab results, treatment history)

2. Schedule B - Authorized Recipients List: Comprehensive list of all authorized recipients and their respective access levels, used when multiple parties are involved

3. Schedule C - Specific Exclusions: List of specific medical information explicitly excluded from the authorization

4. Appendix 1 - Patient Rights Information: Detailed explanation of patient rights under Indonesian law regarding medical information disclosure

5. Appendix 2 - Privacy Notice: Detailed privacy notice explaining how the medical information will be handled and protected

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

Indonesia

Publisher

Ƶ

Document Type

Authorization Form

Cost

Free to use
Relevant legal definitions

























Clauses




















Relevant Industries

Healthcare

Insurance

Medical Services

Pharmaceuticals

Healthcare Technology

Medical Research

Elder Care

Mental Health Services

Rehabilitation Services

Emergency Medical Services

Relevant Teams

Legal

Compliance

Medical Records

Patient Services

Risk Management

Quality Assurance

Operations

Data Protection

Administrative Services

Clinical Operations

Relevant Roles

Medical Director

Hospital Administrator

Compliance Officer

Healthcare Privacy Officer

Medical Records Manager

Clinical Director

Legal Counsel

Risk Management Officer

Patient Services Coordinator

Insurance Coordinator

Healthcare Facility Manager

Medical Information Officer

Data Protection Officer

Quality Assurance Manager

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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