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1. Parties: Identifies the patient (the 'Authorizing Party') and the healthcare provider or institution (the 'Holder of Information')
2. Background: Brief context explaining the purpose of the authorization and the relationship between the parties
3. Definitions: Defines key terms used in the document, including 'Medical Information', 'Authorized Family Members', and 'Healthcare Providers'
4. Scope of Authorization: Details what specific medical information can be released (e.g., test results, diagnoses, treatment plans, medication records)
5. Authorized Family Members: Lists the family members who are authorized to receive the medical information, including their names, relationship to the patient, and contact details
6. Duration and Expiry: Specifies how long the authorization remains valid and any expiry conditions
7. Rights of Revocation: Explains how and when the patient can revoke the authorization
8. Privacy and Confidentiality: States the obligations of authorized family members regarding the confidentiality of received information
9. Execution: Signature blocks for the patient, witness, and acknowledgment by healthcare provider
1. Electronic Access: Include when authorizing access to electronic health records or online patient portals
2. Emergency Contact Provisions: Include when designating specific family members as emergency contacts with special access rights
3. Mental Capacity Provisions: Include when there's a possibility of future mental incapacity, linking to advance directives or lasting powers of attorney
4. Language Preference: Include when the authorized family members require medical information in a specific language
5. Healthcare Provider Instructions: Include when specific instructions for healthcare providers about information sharing methods are needed
1. Schedule 1 - Authorized Family Members Details: Detailed list of authorized family members including full contact information and relationship to patient
2. Schedule 2 - Specific Medical Information Categories: Checklist of specific types of medical information that can be released
3. Appendix A - Verification Requirements: Documents required for family members to verify their identity when requesting information
4. Appendix B - Revocation Form: Standard form for revoking the authorization for specific or all family members
Healthcare
Medical Services
Elder Care
Mental Health Services
Hospital Administration
Private Medical Practice
Public Health
Rehabilitation Services
Family Medicine
Emergency Medical Services
Medical Records
Patient Services
Legal and Compliance
Privacy and Data Protection
Hospital Administration
Clinical Operations
Patient Relations
Healthcare Information Management
Quality Assurance
Risk Management
Medical Records Officer
Privacy Officer
Hospital Administrator
Clinic Manager
Healthcare Compliance Officer
Medical Director
Family Medicine Practitioner
Patient Services Coordinator
Legal Compliance Manager
Healthcare Data Protection Officer
Admissions Manager
Medical Social Worker
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