The Medical Release Form is a crucial document in Belgian healthcare administration that facilitates the authorized sharing of patient medical information while ensuring compliance with privacy laws and regulations. This document is required whenever patient medical information needs to be shared with third parties, whether for continued medical care, insurance purposes, or other authorized uses. It must comply with the Belgian Patient Rights Act, GDPR, and other relevant healthcare regulations. The form includes comprehensive patient identification, specific authorization details, privacy notices, and clear statements of patient rights. It's designed to protect both the healthcare provider and the patient while ensuring efficient medical information transfer.
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1. Patient Information: Full identification details of the patient including name, date of birth, national register number, and contact information
2. Healthcare Provider Information: Details of the healthcare provider(s), facility, or institution requesting the release
3. Purpose of Release: Clear statement of the purpose for which medical information is being released
4. Scope of Authorization: Specific description of what medical information is authorized for release, including time periods covered
5. Duration of Authorization: Timeframe for which the authorization remains valid
6. Privacy Notice: GDPR-compliant privacy statement explaining how information will be handled
7. Rights Statement: Statement of patient rights under Belgian law, including right to revoke authorization
8. Signature Block: Space for patient or legal representative signature, date, and witness if required
1. Legal Representative Authorization: Required when someone other than the patient is authorizing the release (e.g., parent, guardian, or power of attorney)
2. Specific Exclusions: Section listing any specific information the patient does not want released
3. Emergency Contact: Optional section for emergency contact information
4. Electronic Distribution Authorization: Required when medical records may be shared electronically
5. Cross-border Transfer Notice: Required when medical information may be transferred outside Belgium
6. Special Categories Authorization: Required for release of sensitive information like mental health, genetic data, or HIV status
1. Schedule A - Types of Medical Information: Detailed checklist of different types of medical information that can be released
2. Schedule B - Authorized Recipients: List of specific individuals or organizations authorized to receive the medical information
3. Schedule C - Privacy Policy: Detailed privacy policy and data protection information
4. Appendix 1 - Patient Rights Guide: Comprehensive guide to patient rights under Belgian law
5. Appendix 2 - Revocation Form: Form that can be used to revoke the authorization
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