Insurance Authorization Letter Template for Canada

1. Medical Information Details: Used when authorization specifically relates to sharing medical records or specific health information

2. Third Party Authorization: Include when allowing someone other than the policyholder to access information or make decisions

3. Specific Restrictions: Used when placing specific limitations or conditions on the authorization

4. Emergency Contact Information: Include when relevant for medical-related authorizations

5. Revocation Instructions: Optional section detailing how the authorization can be revoked before its expiration

1. Schedule A - List of Authorized Information: Detailed itemization of specific records or information types covered by the authorization

2. Schedule B - Authorized Recipients: List of specific individuals or organizations authorized to receive information

3. Appendix 1 - Supporting Documentation: Copies of relevant identification documents or supporting materials

4. Appendix 2 - Privacy Policy Reference: Copy or summary of relevant privacy policies and procedures