The Medical Authorization Form is a critical document in the Philippine healthcare system, designed to facilitate proper medical care while protecting patient rights and healthcare provider obligations. This document becomes necessary when a patient needs to authorize medical treatment, release of medical information, or delegate medical decision-making authority to another person. It must comply with various Philippine regulations, including the Universal Health Care Act (RA 11223), Data Privacy Act (RA 10173), and relevant Department of Health guidelines. The form serves as legal protection for all parties involved and is particularly important in both routine and emergency medical situations. It includes comprehensive patient information, specific authorizations, temporal validity, and clear delineation of decision-making powers, while ensuring alignment with Philippine medical practice standards and privacy laws.
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1. Patient Information: Complete details of the patient including full name, date of birth, address, contact information, and any relevant identification numbers
2. Healthcare Provider Information: Details of the healthcare provider or facility being authorized, including name, address, and license information
3. Scope of Authorization: Specific medical procedures, treatments, or decisions being authorized, including any limitations or restrictions
4. Duration of Authorization: Time period for which the authorization is valid, including start and end dates if applicable
5. Authorized Representative: Details of the person being authorized to make medical decisions, including their relationship to the patient
6. Privacy Notice: Statement regarding the handling and protection of medical information in compliance with the Data Privacy Act
7. Declaration and Signatures: Formal declaration of understanding and agreement, with spaces for signatures of all relevant parties
1. Special Medical Conditions: Section for listing any existing medical conditions, allergies, or special medical needs - used when the patient has specific medical considerations
2. Emergency Contact Information: Additional emergency contacts beyond the authorized representative - included when multiple contact options are needed
3. Insurance Information: Details of medical insurance coverage and policy numbers - included when authorization relates to insured procedures
4. Specific Treatment Restrictions: List of any procedures or treatments specifically not authorized - used when patient wants to exclude certain medical interventions
5. Religious or Cultural Preferences: Special instructions regarding religious or cultural considerations in medical treatment - included when specific beliefs affect medical decisions
1. Schedule A - Specific Authorized Procedures: Detailed list of specific medical procedures or treatments being authorized
2. Schedule B - Medical History Summary: Brief summary of relevant medical history that may impact treatment decisions
3. Appendix 1 - Witness Attestation: Additional form for witness signatures when required by healthcare facility
4. Appendix 2 - Physician Statement: Form for physician's confirmation of patient's capacity to grant authorization, if required
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