Authorization To Release Medical Information Form Template for Netherlands

A standardized legal document used in the Netherlands that enables patients or their authorized representatives to give permission for the release of their medical information to specified recipients. This form complies with Dutch healthcare laws, including the Medical Treatment Contracts Act (WGBO), and European Union's GDPR requirements. It includes detailed specifications about what medical information can be shared, with whom, for what purpose, and for how long, while ensuring patient privacy rights are protected and properly documented.

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What is a Authorization To Release Medical Information Form?

The Authorization To Release Medical Information Form is a crucial document in the Dutch healthcare system that facilitates the legal and compliant sharing of patient medical information. This document is required whenever medical information needs to be transferred between healthcare providers, shared with insurance companies, or released to other authorized parties. It ensures compliance with the Dutch Medical Treatment Contracts Act (WGBO), the General Data Protection Regulation (GDPR), and other relevant Dutch privacy laws. The form serves as a protection mechanism for both healthcare providers and patients, documenting explicit consent for information sharing while maintaining patient privacy rights. It is particularly important in cases of referrals, insurance claims, legal proceedings, or when patients seek second opinions.

What sections should be included in a Authorization To Release Medical Information Form?

1. Patient Information: Full legal name, date of birth, address, contact information, and any relevant patient ID numbers

2. Healthcare Provider Information: Details of the healthcare provider/institution authorized to release the information, including name, address, and contact details

3. Recipient Information: Details of the person or organization authorized to receive the medical information

4. Information to be Released: Specific description of medical information 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 Authorization: Specification of how long the authorization remains valid

7. Rights and Notices: Statement of patient rights including right to revoke authorization and any limitations

8. Signatures: Space for patient signature, date, and any required witness signatures

What sections are optional to include in a Authorization To Release Medical Information Form?

1. Specific Restrictions: Additional restrictions on the use or re-disclosure of the information (used when patient wants to place specific limitations)

2. Electronic Communication Consent: Specific authorization for electronic transmission of records (used when digital transfer is anticipated)

3. Legal Representative Authorization: Section for cases where someone other than the patient is authorizing the release (used for minors or incapacitated patients)

4. Sensitive Information Specifications: Specific authorization for release of sensitive information like mental health, HIV status, or genetic information (used when such information is involved)

5. Cost Information: Details about any fees associated with the release of information (used when applicable under Dutch law)

What schedules should be included in a Authorization To Release Medical Information Form?

1. Description of Records Checklist: Detailed checklist of specific types of medical records to be released (e.g., consultation notes, test results, imaging reports)

2. Privacy Notice: Detailed information about how the medical information will be protected and handled under GDPR and Dutch law

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok��˰� | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

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Form Giving Medical Permission

A Dutch-law compliant medical permission form for documenting patient consent to medical procedures and treatments in the Netherlands.

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Generate a Bespoke Document

Download a Standard Authorization To Release Medical Information Form

Review your own Authorization To Release Medical Information Form

What is a Authorization To Release Medical Information Form?

What sections should be included in a Authorization To Release Medical Information Form?

What sections are optional to include in a Authorization To Release Medical Information Form?

What schedules should be included in a Authorization To Release Medical Information Form?

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Alex Denne

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