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Authorisation To Release Information
"I need an Authorization to Release Information for my medical records from London Bridge Hospital to be shared with my new healthcare provider in Manchester, valid from January 2025 to December 2025."
1. Authorizing Party Details: Full name, address, and identification of the person giving authorization
2. Recipient Details: Details of the organization/person authorized to receive the information
3. Information Description: Specific description of information to be released
4. Purpose Statement: Clear statement of why the information is being released
5. Duration: Period for which the authorization remains valid
6. Signature Block: Space for signature, date, and witness if required
1. Third Party Recipients: Additional section when information may be shared beyond initial recipient
2. Revocation Rights: Section detailing how authorization can be withdrawn
3. Special Categories: Section for sensitive data like health records or financial information
1. Identity Verification Documents: Copies of ID documents confirming authorizing party's identity
2. Detailed Information List: Itemized list of specific information to be released
3. Privacy Notice: Details of how the information will be processed and protected
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