Authorization To Disclose Health Information Form Template for New Zealand

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Key Requirements PROMPT example:

Authorization To Disclose Health Information Form

"I need an Authorization To Disclose Health Information Form that allows my primary care physician to share my medical history with multiple specialists at Auckland City Hospital, with the authorization valid from January 2025 to December 2025."

Document background

The Authorization To Disclose Health Information Form is a critical document in New Zealand's healthcare system, designed to facilitate the secure and compliant sharing of patient health information. This document becomes necessary when health information needs to be shared between different healthcare providers, insurance companies, legal representatives, or other authorized parties. It ensures compliance with the Health Information Privacy Code 2020 and Privacy Act 2020, providing a formal mechanism for patients to exercise control over their health information. The form includes specific details about what information can be shared, with whom, for what purpose, and for how long, while incorporating necessary privacy protections and patient rights statements. It serves as a legal record of the patient's informed consent and helps healthcare providers maintain appropriate privacy standards while enabling necessary information sharing.

Suggested Sections

1. Patient Information: Full legal name, date of birth, contact details, and any relevant identification numbers (e.g., NHI number)

2. Healthcare Provider Information: Details of the healthcare provider or organization authorized to disclose the information

3. Recipient Information: Details of the person or organization authorized to receive the health information

4. Information to be Disclosed: Specific description of what health information is authorized for disclosure

5. Purpose of Disclosure: Clear statement of why the information is being disclosed

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

7. Patient Rights Statement: Statement of patient's rights under NZ privacy laws, including right to revoke authorization

8. Signature Block: Space for patient (or authorized representative) signature, date, and witness if required

Optional Sections

1. Representative Authorization: Section for cases where someone other than the patient is authorizing disclosure (e.g., parent, guardian, power of attorney)

2. Specific Exclusions: Section to explicitly state any information that should NOT be disclosed

3. Re-disclosure Notice: Statement about whether recipient is authorized to further disclose the information to other parties

4. Emergency Contact: Details of emergency contact person, particularly relevant for ongoing authorizations

5. Special Conditions: Any specific conditions or restrictions on how the information can be used

Suggested Schedules

1. Schedule 1 - Types of Health Information: Detailed checklist of specific types of health information that may be disclosed (e.g., medical records, test results, prescriptions)

2. Schedule 2 - Approved Recipients List: If multiple recipients are authorized, detailed list with full contact information for each

3. Appendix A - Proof of Identity: Requirements and acceptable forms of identification for verification purposes

4. Appendix B - Privacy Statement: Detailed privacy statement explaining how the information will be handled and protected under NZ 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

Authorization Grant
Patient Rights
Confidentiality
Information Disclosure
Duration and Expiry
Revocation Rights
Privacy Protection
Consent
Record Keeping
Information Security
Third Party Access
Liability and Indemnity
Governing Law
Severability
Execution Requirements

Relevant Industries

Healthcare

Medical Services

Mental Health Services

Aged Care

Disability Services

Insurance

Legal Services

Public Health

Pharmaceutical

Allied Health Services

Relevant Teams

Medical Records

Compliance

Legal

Patient Services

Administration

Quality Assurance

Clinical Operations

Privacy and Data Protection

Health Information Management

Front Office Operations

Relevant Roles

Medical Administrator

Privacy Officer

Healthcare Provider

Medical Records Manager

Compliance Officer

Legal Counsel

Healthcare Practice Manager

Clinical Director

Insurance Claims Officer

Medical Secretary

Healthcare Administrator

Quality Assurance Manager

Patient Services Coordinator

Medical Records Clerk

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Online Medical Consent Form

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Let's create your Authorization To Disclose Health Information Form

Authors

Alex Denne

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