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Medical Release Form For Family Members
"I need a Medical Release Form For Family Members that allows my sister and mother to access my medical records from London General Hospital, with specific restrictions on mental health information access, valid for one year from January 2025."
1. Patient Information: Full details of the patient including name, address, date of birth, NHS number
2. Authorized Family Member Details: Information about the family member requesting access, including relationship to patient
3. Scope of Authorization: Specific medical information being authorized for release
4. Duration of Authorization: Time period for which the authorization is valid
5. Declaration and Signature: Formal authorization statement and signature blocks
1. Emergency Contact Information: Additional contacts for urgent situations - used when multiple family members may need access
2. Specific Restrictions: Limitations on information access - used when certain medical information should be excluded
3. Mental Capacity Declaration: Statement regarding patient's capacity - used when patient lacks capacity to make decisions
1. Healthcare Providers List: List of relevant healthcare providers authorized to release information
2. Proof of Identity: Copies of identification documents for authorized family member
3. Power of Attorney Documentation: If applicable, copies of relevant legal authority documents
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