The Medical Authority Form serves as a crucial legal instrument in the Philippine healthcare system, enabling individuals to designate trusted representatives for making medical decisions on their behalf. This document becomes essential when patients may be unable to make their own healthcare decisions, require assistance in managing their medical care, or want to ensure smooth handling of their healthcare matters. The form must comply with various Philippine regulations, including the Universal Health Care Act (RA 11223), Data Privacy Act (RA 10173), and relevant healthcare administrative orders. The Medical Authority Form typically includes comprehensive details about the scope of authority granted, specific healthcare decisions covered, access to medical records, and duration of the authorization, all while incorporating necessary safeguards to protect patient rights and privacy under Philippine law.
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1. Patient Information: Complete details of the patient including full name, date of birth, address, and contact information
2. Authorized Representative: Details of the person being granted medical authority, including their relationship to the patient
3. Scope of Authority: Specific medical decisions and actions the representative is authorized to make on behalf of the patient
4. Duration of Authority: Time period for which the authorization is valid, including start date and expiration conditions
5. Medical Information Release: Authorization for healthcare providers to release medical information to the designated representative
6. Emergency Contact Information: Alternative contacts in case the primary authorized representative cannot be reached
7. Declaration and Signatures: Formal declarations by both patient and representative, with witness signatures as required by Philippine law
1. Specific Treatment Authorizations: Detailed authorizations for specific medical procedures or treatments, used when certain procedures are anticipated
2. International Travel Provisions: Additional authorizations for medical treatment during international travel, included when the patient frequently travels abroad
3. Mental Health Provisions: Specific authorizations related to mental health treatment decisions, included when relevant to patient's condition
4. Religious or Cultural Preferences: Special instructions regarding medical care based on religious or cultural beliefs, included when patient has specific requirements
5. Financial Authority: Authorization to handle medical expenses and insurance claims, included when financial decisions are part of the medical authority
1. Schedule A - Authorized Healthcare Providers: List of specific healthcare providers authorized to release information and provide treatment
2. Schedule B - Prohibited Treatments: List of specific medical treatments or procedures that are explicitly not authorized
3. Appendix 1 - Identification Documents: Copies of valid government IDs of both patient and authorized representative
4. Appendix 2 - Medical History Summary: Brief summary of relevant medical history and current conditions
5. Appendix 3 - Witness Declarations: Additional witness statements and identifications as required by Philippine law
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