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Authorisation To Release Health Care Information
"I need an Authorisation To Release Health Care Information for transferring my complete medical history from London Bridge Hospital to my new GP practice in Manchester, with the authorization valid from 1st March 2025 to 1st June 2025."
1. Patient Information: Full name, date of birth, address, contact details, NHS number of the patient whose records are being requested
2. Healthcare Provider Details: Name, address and contact information of the healthcare provider/organization holding the records
3. Information to be Released: Specific description of the medical information to be disclosed, including type of records and date ranges
4. Purpose of Disclosure: Clear statement of the reason for requesting the information release
5. Recipient Information: Complete details of the person or organization who will receive the information
6. Duration of Authorization: Specified time period for which the authorization remains valid
7. Patient Rights Statement: Comprehensive statement of patient rights under UK GDPR and other applicable laws
8. Signature Block: Designated space for patient/authorized representative signature, date, and declarations
1. Special Instructions: Additional requirements for handling or transmitting the information
2. Representative Authority: Section for documenting legal authority when someone other than the patient is authorizing the release
3. Witness Section: Space for witness details and signature when required by healthcare provider policy
1. Identity Verification Requirements: List of acceptable identification documents and verification procedures
2. Fee Schedule: Schedule of any applicable charges for record copying and processing
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