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1. Patient Information: Full legal name, date of birth, medical record number, contact information, and any other relevant identifying information
2. Healthcare Provider Details: Name and contact information of the healthcare provider/facility currently holding the medical records
3. Recipient Information: Name and contact information of the person or entity authorized to receive the medical information
4. Scope of Release: Specific description of what medical information is to be released (e.g., complete records, specific date ranges, particular conditions or treatments)
5. Purpose of Release: Clear statement of why the medical information is being released
6. Authorization Statement: Explicit statement of authorization for release, including reference to understanding of rights and implications
7. Duration of Authorization: Specification of how long the authorization remains valid
8. Signature Block: Space for patient's (or legal representative's) signature, date, and witness signature if required
1. Legal Representative Authorization: Required when someone other than the patient is authorizing the release, including their relationship to the patient and proof of authority
2. Specific Restrictions: Used when certain parts of the medical record are explicitly not to be released
3. Revocation Rights: Detailed explanation of the right to revoke the authorization and how to do so
4. Special Authorization: Required for sensitive information such as HIV status, mental health records, or substance abuse treatment
5. Cost Information: Include when there are fees associated with the release of records
6. Re-disclosure Notice: Warning about potential re-disclosure by the recipient when relevant
1. Proof of Identity: Copies of valid identification documents of the patient or legal representative
2. Specific Records List: Detailed list of specific medical records to be released when the release is selective
3. Legal Authority Documentation: Power of attorney, court order, or other legal documents proving authority to request records if applicable
4. Medical Record Summary: Summary of the medical records being released, if required
Healthcare
Medical Services
Hospital Administration
Insurance
Legal Services
Clinical Research
Pharmaceutical
Public Health
Healthcare Education
Occupational Health
Medical Records
Legal
Compliance
Patient Services
Health Information Management
Quality Assurance
Risk Management
Operations
Administrative Services
Clinical Coordination
Medical Records Officer
Healthcare Administrator
Medical Director
Compliance Officer
Legal Counsel
Privacy Officer
Clinical Coordinator
Hospital Manager
Healthcare Information Manager
Patient Services Coordinator
Medical Secretary
Quality Assurance Manager
Risk Management Officer
Data Protection Officer
Healthcare Operations Manager
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