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Authorisation To Release Records
"I need an Authorisation To Release Records for my medical history from London General Hospital to be shared with my new specialist doctor in Manchester, valid for 6 months from January 2025."
1. Authorising Party Details: Full name, address, and identifying information of person authorising release
2. Record Holder Details: Identity and contact information of organisation/person holding the records
3. Records Description: Specific description of records to be released
4. Recipient Details: Identity and contact information of person/organisation receiving records
5. Duration: Time period for which authorization is valid
6. Purpose: Stated purpose for which records are being released
7. Signature Block: Space for signature, date, and witness details
1. Special Instructions: Any specific handling or disclosure instructions - use when special handling of records is required
2. Third Party Authorization: Authorization for specific third parties to access records - use when multiple parties need access
3. Revocation Rights: Details of how authorization can be revoked - use when emphasizing right to withdraw consent
1. Identity Verification Documents: Copies of ID documents proving identity of authorising party
2. Specific Records List: Detailed list of specific records to be released if extensive
3. Additional Consents: Any additional consent forms required for specific types of records
Authors
Record Holder
Recipient
Authorised Records
Confidential Information
Data Protection Legislation
Personal Data
Effective Date
Expiry Date
Permitted Purpose
Records
Release
Sensitive Personal Data
Special Categories of Personal Data
Third Party
Processing
Witness
Consent
Data Subject
Authorised Representatives
Scope of Release
Duration and Expiry
Purpose of Release
Data Protection
Confidentiality
Privacy
Consent
Revocation Rights
Record Holder Obligations
Recipient Obligations
Security Measures
Third Party Access
Liability
Indemnification
Governing Law
Execution Requirements
Severability
Entire Agreement
Amendment Rights
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