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1. Guardian/Representative Authorization: Required when consent is given by someone other than the patient, including legal authority verification

2. Emergency Contact: Optional section for including emergency contact details when relevant to the purpose of disclosure

3. Special Categories of Information: Additional consent specifications for sensitive information like mental health records, HIV status, or genetic information

4. Electronic Transfer Consent: Specific consent for electronic transmission of records when applicable

5. Translation Declaration: Required when the form is provided in multiple languages or when translation services were used

6. Fee Acknowledgment: Section addressing any applicable fees for record copying or transfer when relevant

1. Schedule A - Detailed Record List: Itemized list of specific medical records to be released, including dates and types of documents

2. Schedule B - Authorized Recipients: List of all authorized recipients when multiple parties are involved

3. Schedule C - Specific Exclusions: List of any specific information or records explicitly excluded from the release

4. Appendix 1 - Identity Verification Documents: Copies or details of identity documents required for verification

5. Appendix 2 - Legal Authority Documentation: Copies of relevant legal documents for guardian/representative authorization when applicable