Limited Medical Release Form

Limited Medical Release Form Template for England and Wales

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Key Requirements PROMPT example:

"I need a Limited Medical Release Form to allow my GP to share specific medical records about my knee surgery with my insurance company for the next 6 months, starting from January 2025, but excluding any mental health or genetic information."

Document background

The Limited Medical Release Form serves as a critical tool in managing the disclosure of medical information while protecting patient privacy rights under English and Welsh law. This document is essential when specific medical information needs to be shared with third parties for defined purposes, such as insurance claims, legal proceedings, or employment requirements. The form ensures compliance with UK data protection legislation, including GDPR and the Data Protection Act 2018, while providing clear parameters for what information can be shared, with whom, and for how long. It offers protection for both the releasing healthcare provider and the patient by documenting explicit consent and establishing clear boundaries for information sharing.

Suggested Sections

1. Patient Information: Full name, date of birth, address, and contact details of the patient

2. Authorization Statement: Clear statement of what medical information can be released and to whom

3. Time Period: Specific duration for which the authorization is valid

4. Purpose of Release: Stated purpose for which the information will be used

5. Signature Block: Space for patient signature, date, and witness signature if required

Optional Sections

1. Representative Authorization: Used when someone other than the patient is authorized to consent

2. Specific Exclusions: Used when certain medical information should be explicitly excluded from release

3. Emergency Contact: Used when immediate family or emergency contacts need to be listed

4. Revocation Rights: Used to explicitly state the right to withdraw consent

Suggested Schedules

1. List of Authorized Recipients: Detailed list of individuals or organizations authorized to receive information

2. Specific Records Schedule: Itemized list of specific medical records to be released

3. Privacy Notice: Detailed information about how the released data will be handled and protected

Authors

Alex Denne

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

alex.den.21@genieai.co

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Let's create your Limited Medical Release Form

Authors

Alex Denne

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