Consent Form To Disclose Medical Information Template for Nigeria

Create a bespoke document in minutes, or upload and review your own.

4.6 / 5

4.8 / 5

Let's create your Consent Form To Disclose Medical Information

1. Select your governing law and document type:

2. Enter your key requirements:

3. Create your document to edit, review or download

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

Consent Form To Disclose Medical Information

"I need a Consent Form To Disclose Medical Information for a multi-center clinical research study in Lagos, Nigeria, that will run from March 2025 to December 2025, with provisions for sharing anonymized patient data with research institutions in both Nigeria and the UK."

Document background

The Consent Form To Disclose Medical Information is a crucial document used in Nigerian healthcare settings when there is a need to share patient medical information with third parties. This form is essential for compliance with the National Health Act 2014 and the Nigeria Data Protection Regulation (NDPR) 2019, which mandate explicit patient consent for the disclosure of medical information. The document becomes necessary in various scenarios, including insurance claims, referrals to specialists, research participation, or when medical records are requested by other healthcare providers. It contains specific provisions for different types of medical information, including special protections for sensitive data such as HIV/AIDS status, and clearly outlines the rights of the patient regarding their medical information disclosure. The form serves as both a legal protection for healthcare providers and a guarantee of patient privacy rights under Nigerian law.

Suggested Sections

1. Patient Information: Patient's full details including name, date of birth, hospital/medical record number, and contact information

2. Healthcare Provider Details: Details of the healthcare provider/facility currently holding the medical information

3. Purpose of Disclosure: Clear statement of why the medical information is being disclosed and how it will be used

4. Information to be Disclosed: Specific description of what medical information will be shared, including date ranges and types of records

5. Recipient Information: Details of who will receive the medical information, including name, organization, and contact information

6. Duration of Consent: Specification of how long the consent remains valid

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

8. Confidentiality Statement: Statement about how the information will be kept confidential by the recipient

9. Authorization: Formal authorization statement, signature blocks for patient/legal representative and witness

Optional Sections

1. Legal Representative Authorization: Required when someone other than the patient is authorizing the disclosure, including proof of authority

2. Specific Restrictions: Used when patient wants to restrict disclosure of certain information

3. Electronic Transfer Consent: Required when information will be transferred electronically

4. Third Party Payment: Required when disclosure is related to insurance or third-party payment

5. Research Use: Required when information will be used for research purposes

6. HIV/AIDS Information: Special authorization section required for HIV/AIDS-related information as per Nigerian law

Suggested Schedules

1. Schedule A - Types of Medical Information: Detailed checklist of specific types of medical information that may be disclosed

2. Schedule B - Recipient Obligations: Detailed obligations of the recipient regarding confidentiality and use of information

3. Schedule C - Patient Rights Detail: Comprehensive explanation of patient rights regarding their medical information

4. Appendix 1 - Glossary: Definitions of medical and legal terms used in the consent form

5. Appendix 2 - Revocation Form: Form that can be used by patient to revoke consent

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

Research & Development

Pharmaceuticals

Occupational Health

Education

Clinical Trials

Public Health

Corporate HR

Relevant Teams

Legal

Compliance

Medical Records

Patient Services

Administrative Services

Risk Management

Data Protection

Clinical Research

Human Resources

Information Management

Relevant Roles

Medical Records Officer

Healthcare Administrator

Compliance Officer

Legal Counsel

Privacy Officer

Clinical Research Coordinator

Human Resources Manager

Insurance Claims Manager

Medical Secretary

Healthcare Facility Manager

Data Protection Officer

Patient Services Coordinator

Clinical Trial Administrator

Occupational Health Manager

Find the exact document you need

Info Release Form

A Nigerian law-compliant document authorizing the controlled release of information between parties, incorporating NDPR requirements and data protection principles.

How a Sales & Marketing Lead uses Genie AI to reduce contract drafting time by 95%

Let's create your Consent Form To Disclose Medical Information

Authors

Alex Denne

Find the exact document you need

Info Release Form

Authorization To Release Loan Information Form

Authorization For Release Of Medical Record Information

Consent For Medical Records Release Form

Release Of Health Information Form

Doctor Release Form To Return To Work

Court Release Form

Authorization Of Release Of Health Information

Online Medical Consent Form

Employee Medical Release Form

Consent Form To Disclose Medical Information

3rd Party Release Form

Landlord Release Tenant From Lease Form

Medical Photo Consent Form

Legal Release Document

Medical Treatment Authorization And Consent Form

Participant Release Form

Release Of Information Medical Records

Termination Of Account Letter

Employee Media Release Form

Photography Consent Form

Authorization To Disclose Health Information Form

Authorization To Disclose Protected Health Information

Authorization Letter To Release Information

Reference Release Authorization Form

Motor Vehicle Accident Release Form

New Release Form

Minor Consent To Treat Form

Generic Printable Medical Records Release Authorization Form

Employee Key Release Form

Digital Release Form

Temporary Guardian Medical Release Form

Package Release Form

Legal Release Form

Hospital Release Form

Impound Release Form

Actor Release Form

Military Medical Release Form

Credit Release Authorization Form

Written Release Form

Release Of Information Request Form

Medical Information Release Form For Family

Listing Release Form

Company Release Letter To Employee

Authorization Letter For Release Of Medical Records

Medical Release Form For Medical Records

Warrant Release Form

Treatment Release Form

Tenant Information Release Form

Parent Guardian Release Form

Mental Health Records Request Form

Clearance Release Form

Shipment Release Authorization Form

Hospital Authorization Form

General Authorization To Release Information Form

Financial Release Letter

Authorization Release Letter

Verification Of Release Form

Talent Consent Form

Personal Health Information Form

Security Release Form

Medical Release Form For Travel

Medical Consent Form For Family Members

Medical Consent Authorization Form

Employee Medical Consent Form

Consent For Treatment Of A Minor Without Parent Form

Check Release Form

Return To Work Release Form

Release Of Funds Authorization Form

Release And Consent Form

Refund Release Form

Real Estate Property Release Form

Parent Release Form

Mental Health Release Form

Endorsement Release Form