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1. Patient Information: Complete identification details of the patient including full name, Emirates ID, date of birth, contact information, and medical record number if applicable
2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records, including name, address, and license number
3. Recipient Information: Information about the person or entity authorized to receive the health information, including name, address, and relationship to patient
4. Information to be Disclosed: Specific description of the health information to be released, including type of records, date ranges, and any specific conditions or treatments
5. Purpose of Disclosure: Clear statement of the reason for requesting the release of information
6. Duration of Authorization: Specific time period for which the authorization is valid
7. Rights and Notifications: 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 signature if required
1. Specific Restrictions: Optional section for patients to specify any restrictions on the information to be disclosed
2. Legal Representative Authorization: Required only when someone other than the patient is authorizing the disclosure, including proof of authority
3. Sensitive Information Authorization: Special authorization section for sensitive information like mental health, HIV status, or genetic testing results
4. Electronic Distribution Authorization: Optional section for authorizing electronic transmission of records, including specific platforms or methods
5. Translation Confirmation: Required when the form is provided in multiple languages, confirming the patient's understanding
1. Schedule A - Types of Medical Records: Detailed checklist of specific types of medical records that can be disclosed
2. Schedule B - Fee Schedule: If applicable, schedule of fees for record copying and transmission
3. Appendix 1 - Patient Rights Summary: Summary of patient rights regarding medical records and privacy under UAE law
4. Appendix 2 - Revocation Form: Form for revoking the authorization if needed
Healthcare
Medical Services
Healthcare Technology
Insurance
Legal Services
Hospital Administration
Clinical Research
Pharmaceuticals
Healthcare Consulting
Medical Education
Medical Records
Compliance
Legal
Patient Services
Health Information Management
Clinical Operations
Administrative Services
Data Protection
Quality Assurance
Patient Relations
Medical Records Officer
Healthcare Compliance Manager
Privacy Officer
Medical Administrator
Clinical Director
Healthcare Facility Manager
Legal Compliance Officer
Patient Relations Manager
Health Information Manager
Medical Secretary
Healthcare Data Protection Officer
Clinical Operations Manager
Insurance Claims Coordinator
Medical Practice Manager
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