Generic Printable Medical Records Release Authorization Form Template for Nigeria

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Key Requirements PROMPT example:

Generic Printable Medical Records Release Authorization Form

"I need a Generic Printable Medical Records Release Authorization Form for a Lagos-based private hospital that allows the transfer of my complete medical history to a new healthcare provider in Abuja, with the authorization valid from January 15, 2025, to March 15, 2025."

Document background

The Generic Printable Medical Records Release Authorization Form is essential for healthcare providers and patients in Nigeria who need to facilitate the legal and secure transfer of medical information. This document is required whenever patient medical records need to be shared with third parties, whether for continuing medical care, insurance purposes, legal proceedings, or other authorized uses. It complies with the National Health Act 2014, the Nigeria Data Protection Regulation 2019, and other relevant healthcare privacy laws. The form ensures proper documentation of patient consent, specifies the scope of information to be released, and protects healthcare providers from liability while safeguarding patient privacy rights. This standardized format accommodates various types of medical records and can be used across different healthcare facilities throughout Nigeria.

Suggested Sections

1. Patient Information: Complete identification details of the patient including full name, date of birth, address, and contact information

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

3. Recipient Information: Information about the person or entity authorized to receive the medical records

4. Records to be Released: Specific description of medical records authorized for release, including date ranges and types of information

5. Purpose of Disclosure: Statement of the reason for requesting the medical records release

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

7. Rights and Notices: Statement of patient's rights regarding the authorization, including right to revoke and any limitations

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

Optional Sections

1. Special Categories of Records: Additional authorization sections for sensitive information such as HIV/AIDS status, mental health records, or genetic testing - used when such records may be included

2. Legal Representative Authorization: Section for cases where someone other than the patient is authorizing the release, including proof of authority

3. Emergency Contact Information: Additional contact details for urgent situations - used in cases where immediate communication might be necessary

4. Cost and Payment Information: Details about any fees associated with records release - used when the provider charges for records

5. Electronic Records Delivery: Specific provisions for digital transmission of records - used when electronic delivery is an option

Suggested Schedules

1. Schedule A - Detailed Record List: Itemized list of specific medical records being authorized for release

2. Schedule B - Authorized Recipients List: Complete list of all authorized recipients when multiple parties are involved

3. Schedule C - Witness Information: Detailed witness information and requirements where applicable under Nigerian law

4. Appendix 1 - Patient Rights Summary: Detailed explanation of patient rights regarding medical records under Nigerian law

5. Appendix 2 - Privacy Notice: Detailed privacy notice and information handling procedures

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

Consent
Authorization
Patient Rights
Confidentiality
Data Protection
Information Access
Record Identification
Duration
Revocation Rights
Liability
Records Transfer
Privacy Protection
Documentation Requirements
Witness Requirements
Healthcare Provider Obligations
Fee Provisions
Electronic Records Handling
Governing Law
Signature Requirements

Relevant Industries

Healthcare

Insurance

Legal Services

Employment Services

Education

Sports and Athletics

Government Services

Immigration Services

Military and Defense

Social Services

Relevant Teams

Medical Records

Legal

Compliance

Patient Services

Healthcare Administration

Risk Management

Data Protection

Quality Assurance

Clinical Documentation

Information Management

Relevant Roles

Medical Records Officer

Healthcare Administrator

Compliance Officer

Privacy Officer

Medical Director

Legal Counsel

Human Resources Manager

Insurance Claims Processor

Healthcare Facility Manager

Patient Services Coordinator

Data Protection Officer

Clinical Documentation Specialist

Medical Secretary

Healthcare Risk Manager

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Let's create your Generic Printable Medical Records Release Authorization Form

Authors

Alex Denne

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