The Psychiatric Release of Information Form is a crucial document used in the Philippine healthcare system when there is a need to share confidential mental health information with authorized parties. This form becomes necessary when psychiatric records need to be transferred between healthcare providers, shared with insurance companies, or released to other authorized entities. The document ensures compliance with the Philippine Mental Health Act (RA 11036) and Data Privacy Act (RA 10173), incorporating specific provisions for protecting sensitive mental health information while facilitating necessary information exchange. It serves as a legal safeguard for both healthcare providers and patients, documenting explicit consent and establishing clear parameters for information sharing. The form is designed to be comprehensive yet understandable, including all necessary elements required by Philippine law for the valid release of sensitive medical information.
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1. Patient Information: Complete identifying information of the patient including full name, date of birth, address, contact numbers, and patient ID number
2. Healthcare Provider Information: Details of the psychiatric care provider or facility currently holding the records, including name, address, and contact information
3. Recipient Information: Complete details of the person or entity authorized to receive the psychiatric information, including name, address, contact information, and professional credentials if applicable
4. Information to be Released: Specific description of what psychiatric information is authorized for release, including date ranges and types of records
5. Purpose of Disclosure: Clear statement of the reason for releasing the information
6. Duration of Authorization: Specific timeframe for which the authorization is valid
7. Rights and Notices: Statement of patient's rights regarding the authorization, including right to revoke and any limitations
8. Signatures and Date: Space for patient or legal representative signature, date, and witness signatures if required
1. Emergency Contact Authorization: Additional section for authorizing information release to emergency contacts, used when patient wants to designate specific individuals for emergency situations
2. Specific Program Authorization: Special authorization section for specific treatment programs or sensitive information (e.g., substance abuse treatment), used when applicable to patient's care
3. Electronic Records Access: Authorization for digital access to records, used when electronic health records systems are involved
4. Minor Patient Provisions: Additional provisions when the patient is a minor, including parental/guardian authorization requirements
5. Translation Certification: Section certifying that the form has been translated and explained in a language the patient understands, used when patient's primary language is not English or Filipino
1. Schedule A - Detailed Record Types: Comprehensive list of specific types of psychiatric records that may be released, with checkboxes for selection
2. Schedule B - Privacy Notice: Detailed privacy notice in compliance with Philippine Data Privacy Act requirements
3. Schedule C - Revocation Form: Form that can be used by the patient to revoke the authorization
4. Appendix 1 - Glossary of Terms: Definitions of medical and legal terms used in the form
5. Appendix 2 - Patient Rights Summary: Summary of patient rights under Philippine mental health and privacy laws
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Healthcare
Mental Health Services
Medical Administration
Legal Services
Social Services
Insurance
Education
Government Health Services
Private Healthcare
Non-Profit Organizations
Relevant Teams
Legal
Compliance
Medical Records
Mental Health Services
Patient Services
Quality Assurance
Risk Management
Privacy and Data Protection
Administrative Services
Clinical Operations
Relevant Roles
Psychiatrist
Mental Health Counselor
Medical Records Officer
Healthcare Administrator
Privacy Officer
Compliance Manager
Mental Health Nurse
Clinical Director
Social Worker
Insurance Claims Processor
Legal Counsel
Patient Care Coordinator
Medical Secretary
Healthcare Quality Manager
Risk Management Officer
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