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1. Parties: Identification of the person giving consent (data subject), the organization/person authorized to release the information (data controller), and the recipient(s) of the information
2. Background: Brief context explaining the purpose and necessity of the information release
3. Definitions: Clear definitions of key terms used in the form, including types of information, processing activities, and relevant parties
4. Scope of Authorization: Detailed description of what information is authorized for release, including timeframe and purpose
5. Duration of Authorization: Specification of how long the authorization remains valid
6. Rights of the Data Subject: Statement of the individual's rights under the Data Privacy Act, including right to revoke consent
7. Privacy Notice: Statement about how the information will be handled, stored, and protected
8. Limitations and Restrictions: Any restrictions on the use or further disclosure of the released information
9. Representations and Warranties: Confirmations from the data subject regarding their understanding and voluntary consent
10. Execution: Signature blocks and attestation of consent
1. Special Categories of Data: Additional provisions for sensitive personal information such as health records, financial information, or genetic data
2. Minor/Guardian Provisions: Special provisions when the data subject is a minor or under guardianship
3. Emergency Contact Authorization: Specific provisions for releasing information to emergency contacts
4. Digital/Electronic Consent: Additional provisions for electronic execution of the form
5. Third-Party Service Providers: Provisions regarding the use of third-party service providers in processing or handling the information
6. International Transfer: Specific provisions for when information may be transferred outside the Philippines
7. Research Use: Additional provisions for use of information in research or statistical analysis
1. Schedule A - Types of Information: Detailed checklist or listing of specific types of information authorized for release
2. Schedule B - Authorized Recipients: List of specific individuals, organizations, or categories of recipients authorized to receive the information
3. Schedule C - Purpose of Disclosure: Detailed description of authorized purposes for information disclosure
4. Appendix 1 - Consent Revocation Form: Template form for revoking consent
5. Appendix 2 - Privacy Rights Summary: Summary of rights under the Data Privacy Act of 2012
6. Appendix 3 - Security Measures: Description of security measures employed to protect the information during transfer and processing
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