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1. Patient Information: Full legal name, date of birth, address, contact information, and any relevant patient identification numbers or Medicare number
2. Healthcare Provider Details: Name and contact information of the healthcare provider/facility currently holding the medical records
3. Authorized Recipient: Full details of the person or organization authorized to receive the medical records
4. Scope of Authorization: Specific description of what medical records are being authorized for release (e.g., complete records, specific date ranges, particular types of records)
5. Purpose of Disclosure: Clear statement of why the medical records are being requested/released
6. Duration of Authorization: Specification of how long the authorization is valid for
7. Rights Statement: Statement of the patient's rights regarding the authorization, including right to revoke
8. Signatures: Patient's signature (or legal representative), date, and any witness requirements
1. Special Instructions: Any specific handling instructions or restrictions on the use of the records
2. Mental Health Records: Additional authorization language specifically for mental health records, which often require special handling
3. Sensitive Information: Specific authorization for sensitive information like HIV status, genetic testing, or substance abuse treatment
4. Emergency Contact: Details of an emergency contact person, particularly relevant for ongoing authorizations
5. Legal Representative: Details and authority of legal representative if the patient is not signing directly
6. Language Preference: Preferred language for communications and records if different from English
1. Schedule A - List of Specific Records: Detailed list of specific medical records being requested, including dates and types of records
2. Schedule B - Additional Healthcare Providers: List of additional healthcare providers or facilities authorized to release records if there are multiple sources
3. Schedule C - Authorized Recipients: List of multiple authorized recipients if records are to be shared with more than one party
Healthcare
Medical Services
Aged Care
Insurance
Legal Services
Government Health Services
Mental Health Services
Allied Health Services
Disability Services
Corporate Health Services
Legal
Compliance
Medical Records
Patient Services
Health Information Management
Privacy and Data Protection
Administrative Services
Clinical Documentation
Risk Management
Quality Assurance
Medical Records Officer
Privacy Officer
Healthcare Administrator
Medical Practice Manager
Compliance Officer
Legal Counsel
Health Information Manager
Medical Secretary
Patient Services Coordinator
Healthcare Privacy Specialist
Medical Records Clerk
Practice Administrator
Clinical Documentation Specialist
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