The Generic Printable Medical Records Release Authorization Form is essential for healthcare providers and patients in Nigeria who need to facilitate the legal and secure transfer of medical information. This document is required whenever patient medical records need to be shared with third parties, whether for continuing medical care, insurance purposes, legal proceedings, or other authorized uses. It complies with the National Health Act 2014, the Nigeria Data Protection Regulation 2019, and other relevant healthcare privacy laws. The form ensures proper documentation of patient consent, specifies the scope of information to be released, and protects healthcare providers from liability while safeguarding patient privacy rights. This standardized format accommodates various types of medical records and can be used across different healthcare facilities throughout Nigeria.
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1. Patient Information: Complete identification details of the patient including full name, date of birth, address, and contact information
2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records
3. Recipient Information: Information about the person or entity authorized to receive the medical records
4. Records to be Released: Specific description of medical records authorized for release, including date ranges and types of information
5. Purpose of Disclosure: Statement of the reason for requesting the medical records release
6. Duration of Authorization: Specific time period for which the authorization is valid
7. Rights and Notices: Statement of patient's rights regarding the authorization, including right to revoke and any limitations
8. Signatures and Date: Space for patient or legal representative signature, date, and witness signatures if required
1. Special Categories of Records: Additional authorization sections for sensitive information such as HIV/AIDS status, mental health records, or genetic testing - used when such records may be included
2. Legal Representative Authorization: Section for cases where someone other than the patient is authorizing the release, including proof of authority
3. Emergency Contact Information: Additional contact details for urgent situations - used in cases where immediate communication might be necessary
4. Cost and Payment Information: Details about any fees associated with records release - used when the provider charges for records
5. Electronic Records Delivery: Specific provisions for digital transmission of records - used when electronic delivery is an option
1. Schedule A - Detailed Record List: Itemized list of specific medical records being authorized for release
2. Schedule B - Authorized Recipients List: Complete list of all authorized recipients when multiple parties are involved
3. Schedule C - Witness Information: Detailed witness information and requirements where applicable under Nigerian law
4. Appendix 1 - Patient Rights Summary: Detailed explanation of patient rights regarding medical records under Nigerian law
5. Appendix 2 - Privacy Notice: Detailed privacy notice and information handling procedures
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Medical Records
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Patient Services
Healthcare Administration
Risk Management
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Medical Records Officer
Healthcare Administrator
Compliance Officer
Privacy Officer
Medical Director
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Human Resources Manager
Insurance Claims Processor
Healthcare Facility Manager
Patient Services Coordinator
Data Protection Officer
Clinical Documentation Specialist
Medical Secretary
Healthcare Risk Manager
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