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1. Declarant Information: Full name, professional credentials, medical license number, and contact information of the medical professional making the declaration
2. Professional Qualifications: Detailed description of relevant medical qualifications, specializations, and experience that establish expertise
3. Patient Information: Patient's full name, date of birth, insurance number, and relevant identification details (in compliance with privacy laws)
4. Purpose of Affidavit: Clear statement of why the affidavit is being prepared and its intended use
5. Medical Facts/Findings: Detailed description of medical conditions, diagnoses, or observations being attested to
6. Examination Details: Information about when and where medical examinations took place
7. Professional Opinion: Medical professional's expert opinion based on the findings
8. Declaration of Truth: Formal statement declaring that all information provided is true and accurate
9. Signature Block: Space for signature, date, and official stamp/seal
1. Treatment History: Detailed history of treatments and procedures, used when the affidavit requires historical medical context
2. Prognosis: Professional opinion about expected future developments, included when future medical implications are relevant
3. Third-Party Observations: Statements from other medical professionals or witnesses, included when multiple medical opinions are relevant
4. Capacity Assessment: Evaluation of patient's mental capacity and ability to make decisions, included when mental competency is relevant
5. Privacy Notice: Additional privacy and data protection statements, included when the affidavit will be shared with multiple parties
6. Interpreter Certification: Details of interpreter if used for non-German speaking patients
1. Medical Records: Copies of relevant medical records, test results, or imaging reports referenced in the affidavit
2. Professional Credentials: Copies of medical licenses, certifications, and qualifications of the declarant
3. Photographic Evidence: Relevant medical photographs or imaging results (if applicable)
4. Previous Medical Reports: Copies of relevant prior medical reports or affidavits
5. Consent Forms: Copies of patient consent forms for release of medical information
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Disability Services
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Medical Records
Compliance
Risk Management
Patient Services
Insurance Claims
Medical Administration
Quality Assurance
Document Management
Physician
Medical Specialist
Legal Counsel
Insurance Claims Manager
Medical Director
Healthcare Administrator
Occupational Health Officer
Medical Records Officer
Compliance Officer
Risk Management Officer
Patient Services Coordinator
Medical Board Member
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