Patient Disclosure Authorization Form

Patient Disclosure Authorization Form for Malaysia

Patient Disclosure Authorization Form Template for Malaysia

This document is a comprehensive authorization form used in Malaysian healthcare settings that allows patients to give permission for the disclosure of their medical information to specified parties. It complies with Malaysian healthcare privacy laws, including the Personal Data Protection Act 2010 and relevant healthcare regulations. The form captures essential details about the scope of information to be shared, the duration of the authorization, and the specific parties authorized to receive the information, while protecting patient privacy rights and ensuring proper documentation of consent.

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What is a Patient Disclosure Authorization Form?

The Patient Disclosure Authorization Form is a crucial document used in Malaysian healthcare settings to ensure compliance with privacy laws and protect patient rights while facilitating necessary information sharing. This form becomes necessary when medical information needs to be shared with third parties, whether for continued care, insurance purposes, or other legitimate medical or administrative needs. It must comply with the Personal Data Protection Act 2010, the Medical Act 1971, and other relevant Malaysian healthcare regulations. The form includes comprehensive details about the patient, the information to be disclosed, the recipient, and the duration of authorization, while also clearly stating the patient's rights regarding the disclosure of their medical information.

What sections should be included in a Patient Disclosure Authorization Form?

1. Patient Information: Essential identifying information about the patient including full name, IC number, date of birth, and contact details

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

3. Purpose of Disclosure: Clear statement of why the medical information needs to be disclosed

4. Scope of Authorization: Specific description of what medical information is authorized for disclosure

5. Duration of Authorization: Time period for which the authorization remains valid

6. Recipient Information: Details of who is authorized to receive the medical information

7. Patient Rights: Statement of patient's rights including right to revoke authorization

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

What sections are optional to include in a Patient Disclosure Authorization Form?

1. Mental Health Records Authorization: Additional authorization specific to mental health records, required when mental health information is involved

2. Substance Abuse Records: Special authorization for substance abuse treatment records when applicable

3. HIV/AIDS Information: Specific authorization for HIV/AIDS-related information when relevant

4. Minor Patient Details: Additional section for authorization regarding minors, including parent/guardian information

5. Electronic Distribution Authorization: Specific permission for electronic transmission of records when applicable

6. Translation Declaration: For non-English speaking patients, confirmation that form was explained in their preferred language

What schedules should be included in a Patient Disclosure Authorization Form?

1. Schedule A - Types of Medical Information: Detailed list of specific medical information types that may be disclosed (e.g., lab results, imaging reports, prescription records)

2. Schedule B - Authorized Recipients: List of specific individuals or organizations authorized to receive the information

3. Schedule C - Patient Rights Summary: Detailed explanation of patient rights regarding medical information disclosure

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

5. Appendix 2 - Glossary: Definitions of medical and legal terms used in the document

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 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 Patient Disclosure Authorization Form?

What sections should be included in a Patient Disclosure Authorization Form?

What sections are optional to include in a Patient Disclosure Authorization Form?

What schedules should be included in a Patient Disclosure Authorization Form?

Authors

Alex Denne

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