Authorization To Disclose Personal Health Information

Authorization To Disclose Personal Health Information Template for Philippines

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Key Requirements PROMPT example:

"I need an Authorization To Disclose Personal Health Information for a multi-specialty medical clinic in Manila, Philippines, that will allow sharing of patient records with partner hospitals and insurance providers, with special provisions for electronic transmission of records."

Document background

The Authorization To Disclose Personal Health Information is a critical document used in Philippine healthcare settings when patient medical information needs to be shared between healthcare providers or with authorized third parties. This document is essential for compliance with the Data Privacy Act of 2012 and various healthcare regulations in the Philippines. It is typically required when patients need their medical records transferred between healthcare facilities, shared with insurance providers, used for medical research, or disclosed to other authorized parties. The authorization form ensures that patients maintain control over their personal health information while allowing necessary information sharing for continued care or other specified purposes. It includes specific provisions for data protection, clearly defined scope of disclosure, and patient rights as required by Philippine law.

Suggested Sections

1. Parties: Identification of the patient (authorizing party), the healthcare provider/facility releasing the information, and the recipient of the information

2. Background: Brief context explaining the purpose of the authorization form and its compliance with relevant laws

3. Definitions: Clear definitions of key terms used in the authorization, including 'personal health information', 'disclosure', and 'authorized recipient'

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

5. Purpose of Disclosure: Clear statement of the purpose(s) for which the health information may be used

6. Duration of Authorization: Specific period for which the authorization is valid, including start and end dates

7. Rights of the Patient: Statement of the patient's rights under the Data Privacy Act, including right to revoke authorization

8. Revocation Procedure: Process for revoking the authorization, including contact information and required notice

9. Privacy Safeguards: Description of how the information will be protected during transmission and by the recipient

10. Signatures and Declarations: Formal execution section including patient's signature, witness signatures if required, and date

Optional Sections

1. Redisclosure Provisions: Additional provisions regarding whether and how the recipient may redisclose the information to third parties. Include when information may be shared with other healthcare providers or institutions

2. Electronic Transmission Authorization: Specific authorization for electronic transmission of records. Include when digital transfer of records is anticipated

3. Payment Provisions: Details of any fees associated with the record release. Include when the healthcare provider charges for record copying or transmission

4. Emergency Contact Authorization: Authorization for disclosure to emergency contacts. Include when patient wants to pre-authorize information sharing in emergency situations

5. Special Categories of Information: Specific provisions for sensitive information like HIV status, mental health records, or genetic information. Include when such sensitive information may be involved

Suggested Schedules

1. Schedule A - Specific Records Checklist: Detailed checklist of specific medical records authorized for release

2. Schedule B - Authorized Recipients List: List of all authorized recipients and their contact information, if multiple recipients are involved

3. Schedule C - Fee Schedule: Breakdown of any applicable fees for record copying and transmission

4. Appendix 1 - Revocation Form: Standard form for revoking the authorization

5. Appendix 2 - Rights Summary: Summary of patient rights under Philippine data privacy laws regarding medical information

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

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Medical Research

Pharmaceuticals

Education (Medical Institutions)

Legal Services

Government Healthcare

Employee Benefits

Public Health

Healthcare Technology

Relevant Teams

Legal

Compliance

Medical Records

Privacy and Data Protection

Healthcare Operations

Administrative Services

Risk Management

Quality Assurance

Patient Services

Information Management

Relevant Roles

Medical Director

Hospital Administrator

Compliance Officer

Privacy Officer

Medical Records Manager

Healthcare Facility Manager

Legal Counsel

Data Protection Officer

Clinical Director

Insurance Claims Manager

Research Director

Human Resources Manager

Medical Secretary

Healthcare Operations Manager

Quality Assurance Manager

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