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Medical Release Consent Form
"I need a Medical Release Consent Form for my private clinic to share patient records with a research institution, ensuring compliance with GDPR and including specific provisions for anonymizing data before transfer."
1. Patient Information: Full name, date of birth, NHS number, contact details and other identifying information of the patient
2. Purpose of Release: Clear statement of the specific purpose(s) for which medical information is being released
3. Information to be Released: Detailed description of the specific medical information authorized for release, including time periods and types of records
4. Recipient Details: Complete information about who is authorized to receive the medical information, including organization name and contact details
5. Duration of Consent: Specified time period for which the consent remains valid, including start and end dates if applicable
6. Declaration and Signature: Patient's confirmation of understanding and explicit consent, including signature, date, and witness details if required
1. Emergency Contacts: Secondary contacts to be reached if patient is unavailable - recommended for ongoing care arrangements
2. Specific Exclusions: Explicit list of information that the patient does not authorize to be shared or released
3. Third Party Authorization: Authorization for specified individuals to act on patient's behalf, including details of their powers and limitations
4. Capacity Assessment: Assessment of patient's mental capacity to provide consent, required when there are concerns about capacity
1. Information Sheet: Detailed explanation of how the released information will be used, stored, protected, and eventually disposed of
2. Privacy Notice: GDPR-compliant privacy information detailing data protection rights and procedures
3. Withdrawal Form: Template form for withdrawing consent at a later date if the patient chooses to do so
4. Rights Information: Summary of patient's rights under relevant legislation including Data Protection Act 2018 and UK GDPR
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