Medical Authorization Request Form

Medical Authorization Request Form Template for Philippines

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Key Requirements PROMPT example:

"I need a Medical Authorization Request Form for a private hospital in Manila, Philippines, that will cover a series of outpatient physical therapy treatments from January to June 2025, with specific provisions for PhilHealth coverage and the option for treatment plan modifications."

Document background

The Medical Authorization Request Form is a critical document used in Philippine healthcare settings to obtain and document patient consent for medical procedures, treatments, or release of medical information. This form is required under various Philippine healthcare regulations, including the Universal Health Care Act and Data Privacy Act of 2012, and must be completed before any non-emergency medical procedure. It serves multiple purposes: documenting informed consent, meeting insurance/PhilHealth requirements, ensuring compliance with privacy laws, and protecting both healthcare providers and patients. The form typically includes detailed patient information, specific procedure details, insurance information, and clear authorization statements. It's particularly important for procedures requiring pre-authorization from insurance providers or PhilHealth, and forms part of the patient's official medical record.

Suggested Sections

1. Patient Information: Complete details of the patient including full name, date of birth, address, contact information, and patient ID numbers

2. Healthcare Provider Information: Details of the healthcare facility and primary healthcare provider requesting authorization

3. Medical Procedure/Treatment Details: Specific description of the medical procedure, treatment, or service requiring authorization

4. Insurance Information: Patient's health insurance details including policy number and coverage information

5. Authorization Statement: Clear statement of what is being authorized, including scope and duration of the authorization

6. Privacy Notice: Statement regarding how medical information will be used and protected in compliance with the Data Privacy Act

7. Signature Block: Space for patient or authorized representative's signature, date, and witness signatures

Optional Sections

1. Emergency Contact Information: Details of person to contact in case of emergency - included when requested by patient or required by facility

2. Authorized Representatives: Information about persons authorized to make decisions on patient's behalf - used when patient is a minor or has designated representatives

3. Special Medical Conditions: Section for listing relevant medical conditions that may affect treatment - included when applicable

4. Language Preference: Patient's preferred language for medical communications - included in facilities serving diverse populations

5. Religious/Cultural Considerations: Special religious or cultural preferences affecting medical care - included when relevant

6. Advance Directives Reference: Reference to any existing advance directives - included for major procedures or when requested

Suggested Schedules

1. Schedule A - Procedure Details: Detailed technical description of the medical procedure or treatment plan

2. Schedule B - Cost Estimate: Estimated costs and payment requirements for the authorized procedure

3. Schedule C - Supporting Medical Documentation: List of attached medical records, test results, or other supporting documents

4. Appendix 1 - Patient Rights: Summary of patient rights and responsibilities under Philippine healthcare laws

5. Appendix 2 - Facility Policies: Relevant hospital or facility policies affecting the authorized procedure

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 Services

Healthcare Administration

Pharmaceutical

Medical Device

Healthcare Technology

Social Services

Elder Care

Rehabilitation Services

Relevant Teams

Medical Administration

Patient Services

Legal and Compliance

Medical Records

Insurance Processing

Quality Assurance

Clinical Operations

Privacy and Data Protection

Patient Care Coordination

Healthcare Documentation

Relevant Roles

Medical Director

Hospital Administrator

Healthcare Facility Manager

Nurse Manager

Medical Records Officer

Compliance Officer

Insurance Coordinator

Patient Services Representative

Medical Secretary

Healthcare Legal Counsel

Privacy Officer

Quality Assurance Manager

Clinical Operations Manager

Medical Office Administrator

Patient Care Coordinator

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Authors

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