The Consent To Release Medical Information Form serves as a critical document in Nigerian healthcare settings, enabling the authorized sharing of patient medical records while maintaining compliance with privacy laws and regulations. This document is essential when medical information needs to be shared between healthcare providers, insurance companies, legal representatives, or other authorized parties. It must align with the National Health Act 2014, the Nigeria Data Protection Regulation (NDPR) 2019, and other relevant healthcare regulations. The form includes comprehensive patient identification, specific details about the information to be released, the purpose of disclosure, and clear statements about patient rights. It's designed to protect both the patient's privacy rights and the healthcare provider's legal obligations while facilitating necessary information sharing.
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1. Patient Information: Complete identification details of the patient including full name, date of birth, address, phone number, and medical record number/hospital ID
2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records, including name, address, and contact information
3. Recipient Information: Details of the person or entity to whom the medical information will be released, including name, address, and relationship to patient
4. Information to be Released: Specific description of what medical information is authorized for release, including date ranges and types of records
5. Purpose of Disclosure: Clear statement of the reason for releasing the medical information
6. Duration of Consent: Specification of how long the authorization remains valid
7. Patient Rights Statement: Statement of patient's rights regarding the consent, including right to revoke and any limitations
8. Signatures and Date: Space for patient or authorized representative signature, date, and witness signature if required
1. Authorized Representative Details: To be included when someone other than the patient is authorizing the release, including legal authority documentation
2. Specific Consent for Sensitive Information: Additional consent section for HIV/AIDS information, mental health records, or substance abuse treatment records
3. Translation Declaration: To be included when the form has been translated or when an interpreter has been used to explain the content
4. Electronic Distribution Authorization: Special authorization for electronic transmission of records, if applicable
5. Fee Disclosure: Information about any applicable fees for record copying or transmission, if relevant
1. Schedule A - Types of Medical Information: Detailed checklist of specific types of medical information that can be released (e.g., lab results, imaging reports, consultation notes)
2. Schedule B - Privacy Notice: Detailed explanation of how the medical information will be used and protected, including relevant NDPR provisions
3. Schedule C - Patient Rights Guide: Comprehensive guide to patient rights regarding medical information and privacy under Nigerian law
4. Appendix 1 - Glossary of Terms: Definitions of medical and legal terms used in the form
Relevant legal definitions
Clauses
Relevant Industries
Healthcare
Insurance
Legal Services
Pharmaceuticals
Medical Research
Education (Medical Institutions)
Occupational Health
Public Health
Social Services
Healthcare Technology
Relevant Teams
Legal
Compliance
Medical Records
Patient Services
Administration
Quality Assurance
Data Protection
Healthcare Operations
Risk Management
Information Management
Relevant Roles
Medical Records Officer
Healthcare Administrator
Compliance Officer
Legal Counsel
Privacy Officer
Clinical Director
Hospital Administrator
Insurance Claims Manager
Medical Secretary
Healthcare Data Manager
Patient Services Coordinator
Quality Assurance Manager
Medical Research Coordinator
Healthcare Operations Manager
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