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Release Of Information Form Mental Health Template
I need a Release Of Information Form Mental Health Template for transferring patient records from our London clinic to a specialist treatment facility in Manchester, with specific provisions for ongoing therapy notes and medication history over the next six months starting January 2025.
1. Patient Information: Basic identifying information about the patient including name, date of birth, address, and contact details
2. Authorization Statement: Clear statement confirming the patient's consent to release specified mental health information
3. Purpose of Disclosure: Specific reason for information release, including intended use of the information
4. Information to be Released: Detailed specification of which mental health records are to be shared, including date ranges and types of records
5. Duration of Authorization: Time period for which the authorization is valid, including start and end dates
6. Recipient Information: Details of who will receive the information, including organization name, contact person, address and contact details
7. Signature Block: Space for patient/guardian signature, date, and witness signature if required
1. Special Conditions: Section for specifying any restrictions or limitations on how the information can be used or shared
2. Third Party Authorization: Section for cases where someone other than the patient is authorized to request or receive information
3. Emergency Contact: Section for including details of emergency contact person and their relationship to the patient
4. Capacity Assessment: Section for documenting assessment of patient's capacity to consent when relevant
1. Privacy Notice: Detailed information about how personal data will be handled in compliance with UK GDPR and Data Protection Act 2018
2. Rights Information: Summary of patient rights regarding their information under relevant mental health and data protection legislation
3. Revocation Instructions: Detailed instructions on how to withdraw consent and the process for revoking this authorization
4. Legal Framework Reference: Summary of relevant legislation and regulations governing the release of mental health information
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