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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
2. Healthcare Provider Details: Information about the healthcare provider/facility currently holding the medical records
3. Recipient Information: Details of the person or entity to whom the medical information will be released
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: Specific timeframe for which the authorization is valid
7. Rights and Notifications: Statement of patient's rights including right to revoke consent and any limitations
8. Signatures and Date: Space for patient or legal representative signature, date, and witness signature if required
1. Legal Representative Authorization: Additional section when the consent is being given by a legal representative rather than the patient directly
2. Specific Exclusions: Section to explicitly state any parts of the medical record that should NOT be released
3. Electronic Transmission Authorization: Additional authorization specifically for electronic transmission of records, if applicable
4. Translation Confirmation: For non-Arabic speaking patients, confirmation that the form has been explained in their preferred language
5. Emergency Contact Information: Additional contact information section for urgent matters related to the information release
1. Schedule A - Types of Medical Information: Detailed checklist of specific types of medical information that can be released (e.g., lab results, imaging reports, prescriptions)
2. Schedule B - Authorized Recipients List: If multiple recipients are authorized, detailed list with specific permissions for each
3. Schedule C - Fee Schedule: If applicable, breakdown of any administrative fees associated with the release of medical information
4. Appendix 1 - Patient Rights Summary: Detailed explanation of patient rights regarding medical information in accordance with UAE law
Healthcare
Insurance
Legal Services
Healthcare Technology
Medical Research
Pharmaceuticals
Healthcare Administration
Public Health
Employee Benefits
Medical Education
Medical Records
Compliance
Legal
Patient Relations
Health Information Management
Quality Assurance
Risk Management
Data Protection
Clinical Administration
Insurance Coordination
Medical Records Officer
Compliance Manager
Healthcare Administrator
Legal Counsel
Privacy Officer
Medical Director
Insurance Coordinator
Patient Relations Manager
Health Information Manager
Clinical Documentation Specialist
Medical Secretary
Healthcare Facility Manager
Quality Assurance Officer
Risk Management Director
Data Protection Officer
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