Physician Medical Release Form

Physician Medical Release Form Template for England and Wales

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Key Requirements PROMPT example:

"I need a Physician Medical Release Form to authorize my GP to share my complete medical history with a specialist consultant at London Bridge Hospital, with the authorization valid from March 1, 2025, to September 1, 2025."

Document background

The Physician Medical Release Form is essential in situations where medical information needs to be shared between healthcare providers and authorized parties while maintaining compliance with UK privacy laws. This document is commonly used when patients need their medical information shared with specialists, insurance companies, employers, or legal representatives. The form ensures compliance with UK GDPR, the Data Protection Act 2018, and medical confidentiality requirements, while providing clear documentation of consent. It specifies what information can be released, to whom, and for what purpose, protecting both the healthcare provider and patient interests under English and Welsh jurisdiction.

Suggested Sections

1. Patient Information: Full name, date of birth, address, NHS number, and other identifying information

2. Healthcare Provider Details: Physician name, practice details, registration number, and contact information

3. Scope of Release: Detailed description of specific medical information being authorized for release

4. Purpose of Release: Clear statement of intended use and recipients of the medical information

5. Duration of Authorization: Specific time period for which the release authorization remains valid

6. Data Protection Statement: Information about how the released data will be protected and handled under UK GDPR

7. Consent Declaration: Express authorization statement and acknowledgment of understanding

8. Signature Section: Space for patient/authorized representative signature, date, and witness details

Optional Sections

1. Third Party Authorization: Details of authorized third parties when information is to be released to someone other than the patient

2. Capacity Assessment: Section addressing mental capacity when relevant under Mental Capacity Act 2005

3. Specific Exclusions: List of any medical information specifically excluded from the release authorization

4. Emergency Contact: Alternative contact details for urgent communication needs

5. Revocation Rights: Information about the right to revoke the authorization and process for doing so

Suggested Schedules

1. Schedule 1: Identity Verification Documents: Copies of identification documents used to verify patient identity

2. Schedule 2: Proof of Authority: Documentation proving authority to act on patient's behalf, if applicable

3. Schedule 3: Specific Records List: Detailed inventory of specific medical records being authorized for release

4. Schedule 4: Data Protection Notice: Detailed information about data protection rights under UK GDPR and Data Protection Act 2018

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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Authors

Alex Denne

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