Authorization For Release Of Protected Health Information Template for Nigeria

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Key Requirements PROMPT example:

Authorization For Release Of Protected Health Information

"I need an Authorization for Release of Protected Health Information for a Nigerian hospital to share my complete medical history with a specialist clinic in London, including provisions for electronic transmission of records and translation requirements, valid from March 2025 to September 2025."

Document background

The Authorization For Release Of Protected Health Information is a crucial document in the Nigerian healthcare system, designed to facilitate the legal and secure transfer of patient medical information while protecting patient privacy rights. This document becomes necessary when patient information needs to be shared between healthcare providers, or with third parties such as insurance companies, legal representatives, or other authorized recipients. It ensures compliance with the National Health Act 2014 and the Nigeria Data Protection Regulation (NDPR) 2019, which govern the handling of sensitive medical information. The authorization form serves as both a patient's consent mechanism and a healthcare provider's documentation of proper information sharing procedures, protecting all parties involved in the information transfer process.

Suggested Sections

1. Patient Information: Complete identifying information of the patient including full name, date of birth, address, phone number, and medical record number if applicable

2. Healthcare Provider Information: Details of the healthcare provider/facility authorized to release the information, including name, address, and contact information

3. Recipient Information: Details of the person or entity to whom the information will be released, including name, address, and contact information

4. Information to be Released: Specific description of the health information to be released, including type of records, date ranges, and any specific exclusions

5. Purpose of Disclosure: Clear statement of the purpose for which the information is being released

6. Duration of Authorization: Specific time period for which the authorization is valid

7. Rights and Notifications: Statement of patient's rights including right to revoke authorization and any limitations

8. Signatures and Date: Space for patient or legal representative signature, date, and witness if required

Optional Sections

1. Special Categories of Information: Additional authorization sections for sensitive information such as HIV status, mental health records, or genetic information - used when such specific information might be included in the records

2. Legal Representative Authorization: Section for details and documentation of legal representative's authority - used when someone other than the patient is authorizing the release

3. Electronic Transmission Authorization: Specific authorization for electronic transmission of records - used when records may be sent electronically

4. Payment Information: Section detailing any fees associated with the release of information - used when the facility charges for records

5. Translator Certification: Section for translator details and certification - used when the form is explained to the patient in another language

Suggested Schedules

1. Schedule A - Types of Medical Records: Detailed checklist of specific types of medical records that can be released (e.g., laboratory results, imaging reports, consultation notes)

2. Schedule B - Fee Schedule: If applicable, detailed breakdown of fees for different types of record releases

3. Appendix 1 - Glossary of Terms: Definitions of medical and legal terms used in the authorization form

4. Appendix 2 - Patient Rights Summary: Detailed explanation of patient rights regarding their medical records under Nigerian law

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Legal Services

Government/Public Sector

Education

Research Institutions

Pharmaceuticals

Occupational Health

Sports and Athletics

Social Services

Relevant Teams

Legal

Compliance

Medical Records

Patient Services

Healthcare Administration

Risk Management

Data Protection

Quality Assurance

Human Resources

Information Technology

Relevant Roles

Medical Director

Healthcare Administrator

Compliance Officer

Medical Records Officer

Privacy Officer

Legal Counsel

Healthcare Provider

Insurance Claims Manager

Human Resources Manager

Occupational Health Manager

Research Administrator

Data Protection Officer

Quality Assurance Manager

Patient Services Coordinator

Medical Secretary

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Authors

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