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1. Patient Information: Full legal name, date of birth, contact details, and any relevant patient identification numbers
2. Requesting Party Details: Name and contact information of the healthcare provider, institution, or individual requesting the records
3. Records Holder Information: Details of the current healthcare provider or facility holding the medical records
4. Records Description: Specific description of medical records being requested, including date ranges and types of records
5. Authorization Statement: Clear statement of consent authorizing the release of specified medical records
6. Purpose of Release: Stated purpose for why the medical records are being requested and how they will be used
7. Duration of Authorization: Specific timeframe for which the authorization is valid
8. Patient Rights Statement: Statement informing the patient of their rights regarding the release of their medical records
9. Signature Block: Space for patient or authorized representative's signature, date, and witness if required
1. Urgent Request Indication: Section to indicate if this is an urgent or expedited request, used when immediate access to records is required
2. Specific Restrictions: Used when patient wants to exclude certain information from being released or specify particular restrictions
3. Mental Health Records Authorization: Additional authorization section specifically for mental health records, used when mental health records are included
4. Third Party Authorization: Used when someone other than the patient is authorized to request records
5. Information Sharing Limitations: Section specifying limitations on how the released information can be used or shared
6. Electronic Records Format: Section specifying if records are to be provided in electronic format and any specific requirements
1. Detailed Records List: Itemized list of specific medical records being requested
2. Identity Verification Documents: Copies of required identification documents to verify patient identity
3. Proof of Authority: Documentation proving authority to act on patient's behalf (if applicable)
4. Fee Schedule: Schedule of any applicable fees for records release
5. Special Consent Forms: Additional consent forms required for specific types of medical information (e.g., HIV status, genetic information)
Healthcare
Medical Insurance
Legal Services
Healthcare Technology
Medical Research
Aged Care
Mental Health Services
Public Health
Disability Services
Allied Health Services
Medical Records
Compliance
Legal
Patient Services
Healthcare Administration
Privacy and Data Protection
Clinical Operations
Information Management
Quality Assurance
Risk Management
Medical Records Officer
Healthcare Administrator
Privacy Officer
Compliance Manager
Medical Practice Manager
Health Information Manager
Clinical Director
Medical Secretary
Legal Compliance Officer
Healthcare Privacy Specialist
Patient Services Coordinator
Medical Records Clerk
Practice Administrator
Healthcare Operations Manager
Records Management Supervisor
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ұԾ’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
Your documents are private:
We do not train on your data; ұԾ’s AI improves independently
All data stored on Genie is private to your organisation
Your documents are protected:
Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it


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