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1. Emergency Contacts: Additional authorized persons to be contacted in emergency situations

2. Special Conditions: Any specific conditions or restrictions on the use or disclosure of the information

3. Electronic Distribution: Specific provisions for electronic transmission of records, if applicable

4. Interstate/International Transfer: Additional provisions for when information will be sent across state or national borders

5. Capacity Declaration: Required when consent is given by someone other than the patient (e.g., guardian, power of attorney)

6. Fee Schedule: If applicable, details of any fees associated with the release of information

1. Schedule A - Types of Information: Detailed checklist of specific types of medical information to be released (e.g., test results, imaging, medications)

2. Schedule B - Authorized Recipients: List of all authorized recipients and their contact details, if multiple recipients are involved

3. Schedule C - Identification Documents: List of acceptable identification documents required for verification

4. Appendix 1 - Revocation Form: Template form for revoking consent

5. Appendix 2 - Privacy Policy Summary: Summary of relevant privacy policies and procedures