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1. Patient Information: Complete identification details of the patient including name, date of birth, address, and contact information
2. Healthcare Provider Information: Details of the healthcare provider or facility currently holding the medical records
3. Recipient Information: Information about the person or entity authorized to receive the medical records
4. Scope of Authorization: Specific description of what medical information is authorized for release, including date ranges
5. Purpose of Disclosure: Statement of the reason for releasing the medical information
6. Duration of Authorization: Specific time period for which the authorization remains valid
7. Rights and Notices: Statement of patient's rights regarding the authorization, including right to revoke
8. Signatures: Space for patient or legal representative signature, date, and witness signatures if required
1. Special Authorization for Sensitive Information: Additional authorization for release of sensitive information such as HIV status, mental health records, or substance abuse treatment
2. Electronic Records Transfer Authorization: Specific authorization for electronic transmission of records, including email or digital platform preferences
3. Emergency Contact Information: Details of emergency contacts who may be consulted regarding the release
4. Translation Declaration: For non-English speaking patients, confirmation that the form has been explained in their preferred language
5. Legal Representative Authorization: Additional section when the authorization is signed by someone other than the patient, including proof of authority
1. Schedule A - Specific Records Checklist: Detailed checklist of specific medical records authorized for release
2. Schedule B - Fee Schedule: List of any applicable fees for medical records copying and transmission
3. Appendix 1 - Revocation Form: Form to be used if patient wishes to revoke the authorization
4. Appendix 2 - Proof of Identity Requirements: List of acceptable identification documents for verification
Healthcare
Insurance
Legal Services
Medical Research
Education (Medical Institutions)
Government Healthcare
Pharmaceutical
Healthcare Technology
Social Services
Medical Records
Compliance
Legal
Patient Services
Administration
Privacy and Data Protection
Clinical Operations
Insurance Processing
Quality Assurance
Information Management
Medical Records Administrator
Healthcare Facility Manager
Compliance Officer
Medical Secretary
Insurance Claims Processor
Healthcare Privacy Officer
Medical Legal Advisor
Clinical Research Coordinator
Patient Services Coordinator
Medical Office Manager
Healthcare Administrator
Medical Information Officer
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