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Doctor Release Form
"I need a Doctor Release Form to authorize the release of my medical records from London Bridge Hospital to my insurance company for a claim related to my surgery in March 2025, with the authorization valid for 3 months."
1. Patient Information: Patient's full name, date of birth, address, NHS number and other identifying details
2. Doctor Information: Doctor's name, GMC number, practice details and professional information
3. Purpose of Release: Clear statement of the specific reason for information release and intended use
4. Scope of Release: Detailed description of exactly what medical information is being authorized for release
5. Recipient Details: Complete information about who is authorized to receive the medical information
6. Duration of Authorization: Specific time period for which the release authorization remains valid
7. Consent Statement: Formal statement of patient consent including acknowledgment of understanding
1. Third Party Authorization: Additional section for cases where someone other than the patient is authorizing the release (e.g., for minors or patients lacking capacity)
2. Specific Exclusions: Section detailing any specific medical information that is explicitly not to be released
3. Emergency Contact Information: Alternative contact details for urgent matters or emergency situations
1. Identity Verification Documents: Copies of identification documents used to verify the patient's identity
2. Proof of Authority Documentation: Legal documentation proving authority to act on patient's behalf, where applicable
3. Specific Records List: Detailed inventory of specific medical records authorized for release
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