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The Consent Form To Release Medical Information To A Third Party is a critical document in South African healthcare administration that enables the authorized sharing of medical information while maintaining patient privacy rights. This document becomes necessary when medical information needs to be shared with entities other than the primary healthcare provider, such as insurance companies, employers, or other medical practitioners. It ensures compliance with South African legislation, particularly POPIA and the National Health Act, by obtaining explicit patient consent for the release of confidential medical information. The form specifies the scope of information to be shared, the intended recipient, the purpose of disclosure, and the duration of the authorization, while also informing the patient of their rights regarding their medical information.

1. Patient Information: Full details of the patient including name, ID number, date of birth, contact information, and medical record number

2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical information

3. Recipient Information: Details of the third party who will 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: Validity period of the consent and expiration date

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

8. Privacy Notice: POPIA-compliant privacy notice regarding the handling of personal health information

9. Authorization Statement: Formal declaration of consent and understanding of the terms

10. Signatures: Space for patient (or authorized representative) signature, date, and witness signatures