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General Authorisation To Release Information Form
"I need a General Authorisation To Release Information Form that allows my medical records to be shared between my current GP and a specialist consultant for a period of 6 months starting from January 2025, with specific provisions for maintaining confidentiality of mental health records."
1. Subject Information: Full details of the person whose information is being released, including full name, address, date of birth, and any relevant identification numbers
2. Authorisation Statement: Clear and explicit statement of consent authorizing the release of specified information, acknowledging understanding of data protection rights
3. Information Scope: Detailed description of what information can be released, including type of information, time period covered, and any specific exclusions
4. Recipient Details: Complete information about who is authorized to receive the information, including organization name, contact person, address and contact details
5. Duration: Specific timeframe for which the authorization remains valid, including start date and expiration date
6. Signature Block: Space for formal execution including date, signature of the subject, witness signature if required, and any notarization requirements
1. Purpose Statement: Specific purpose for which the released information can be used, including any restrictions on use or further disclosure
2. Third Party Authorization: Details and authority of any third parties authorized to act on behalf of the subject, including relationship to subject and scope of authority
3. Revocation Clause: Detailed process for withdrawing consent, including contact information and any notice requirements
4. Data Protection Notice: Information about rights under data protection laws, including right to withdraw consent and lodge complaints with supervisory authorities
1. Schedule A - List of Specific Records: Detailed inventory of specific documents, records, or information to be released, including dates and reference numbers where applicable
2. Schedule B - Proof of Identity: Requirements and copies of acceptable identification documents to verify the identity of the subject
3. Schedule C - Power of Attorney: Where applicable, documentation proving legal authority to act on behalf of the subject, including any restrictions or limitations
4. Schedule D - Privacy Notice: Detailed information about how the released information will be processed, stored, and protected by the recipient
Authors
Scope of Information
Duration and Expiry
Purpose of Disclosure
Confidentiality
Data Protection
Consent
Revocation Rights
Third Party Rights
Liability
Governing Law
Representations and Warranties
Execution Requirements
Notice Requirements
Privacy Protection
Information Security
Record Keeping
Permitted Recipients
Variation
Severability
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