Patient Information Release Form Template for United Arab Emirates

A Patient Information Release Form is a critical legal document used in UAE healthcare settings to authorize and facilitate the controlled release of patient medical information. This document, governed by UAE Federal Law No. 2 of 2019 (Health Data Law) and related healthcare regulations, establishes the scope, purpose, and conditions under which patient medical information can be disclosed to authorized parties. It includes comprehensive details about the patient, requesting party, specific information to be released, and ensures compliance with UAE data protection and healthcare privacy requirements. The form serves as both a legal authorization and a record of consent, protecting the rights of patients while enabling necessary information sharing within the UAE healthcare system.

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What is a Patient Information Release Form?

The Patient Information Release Form is an essential document used in UAE healthcare settings when there is a need to share patient medical information with authorized parties. This form is required under UAE Federal Law No. 2 of 2019 and related healthcare regulations whenever patient information needs to be disclosed to third parties, transferred between healthcare providers, or released for specific purposes such as insurance claims or legal proceedings. The document ensures proper documentation of consent, protects patient privacy rights, and establishes clear parameters for information sharing. It includes crucial details such as patient identification, scope of information to be released, duration of authorization, and intended recipients. Healthcare providers in the UAE must maintain these forms as part of their legal compliance and medical records management system.

What sections should be included in a Patient Information Release Form?

1. Patient Information: Basic details of the patient including full name, Emirates ID, date of birth, contact information, and medical record number

2. Requesting Party Details: Information about the person/entity requesting access to the medical records, including their relationship to the patient if not the patient themselves

3. Information to be Released: Specific description of medical information authorized for release, including date ranges and types of records

4. Purpose of Release: Clear statement of the reason for requesting the medical information

5. Duration of Authorization: Validity period of the authorization and expiry date

6. Release Method: Specification of how the information will be transmitted or accessed

7. Patient Rights Statement: Statement of patient's rights regarding the release of information, including right to revoke authorization

8. Confidentiality Statement: Statement regarding the confidential handling of released information and restrictions on further disclosure

9. Signatures and Attestation: Space for required signatures, including patient/guardian, witness, and healthcare provider representative

What sections are optional to include in a Patient Information Release Form?

1. Guardian Authorization: Additional section for cases where the patient is a minor or legally incapacitated

2. Specific Exclusions: Section to explicitly state any information that should NOT be released

3. Emergency Contact: Optional inclusion of emergency contact information

4. Fee Schedule: Information about any applicable fees for record retrieval and copying, if relevant

5. Third Party Authorization: Additional authorization details when information is to be released to third parties other than the requesting party

What schedules should be included in a Patient Information Release Form?

1. Schedule A - Types of Medical Records: Detailed checklist of different types of medical records that can be released (e.g., lab results, imaging reports, consultation notes)

2. Schedule B - Authorized Recipients List: List of specific individuals or entities authorized to receive the information, if multiple recipients are involved

3. Appendix 1 - Identity Verification Requirements: Documentation requirements for verifying the identity of the requesting party

4. Appendix 2 - Privacy Policy Summary: Summary of relevant privacy policies and patient rights under UAE law

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Generate a Bespoke Document

Download a Standard Patient Information Release Form

Review your own Patient Information Release Form

What is a Patient Information Release Form?

What sections should be included in a Patient Information Release Form?

What sections are optional to include in a Patient Information Release Form?

What schedules should be included in a Patient Information Release Form?

Authors

Alex Denne

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