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Authorisation For Disclosure Of Information Form
"I need an Authorisation For Disclosure Of Information Form to allow my new employer to access my medical records from my previous GP practice for the next 12 months, starting from January 2025, specifically relating to my occupational health assessments."
1. Data Subject Details: Full name, contact details, and identification information of the person whose information will be disclosed
2. Authorisation Statement: Clear statement of consent for disclosure
3. Scope of Disclosure: Specific information to be disclosed and its purpose
4. Recipient Details: Identity and contact details of the person/organization receiving the information
5. Duration: Time period for which the authorisation is valid
6. Signature Block: Space for data subject's signature and date
1. Third Party Authorization: Additional section required when someone other than the data subject is authorizing disclosure (e.g., for minors or individuals lacking capacity)
2. Special Category Data: Additional consent section specifically for sensitive personal data such as health, biometric, or other sensitive information
3. Revocation Clause: Section detailing the process for withdrawing consent, particularly relevant for ongoing or multiple disclosures
1. Identity Verification Documents: Schedule listing acceptable ID documents and containing copies of provided identification
2. Proof of Authority: Schedule containing power of attorney or other authority documentation when relevant
3. Data Categories Checklist: Detailed checklist of specific information types authorized for disclosure
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