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Permission To Release Information Form
"I need a Permission To Release Information Form that allows my medical records to be shared between my current GP and a specialist clinic for a period of 6 months starting March 2025, with specific provisions for sharing diagnostic imaging results."
1. Personal Details: Information about the person giving permission (name, address, contact details)
2. Information Description: Clear description of what information is being authorized for release
3. Recipient Details: Who is authorized to receive the information
4. Purpose Statement: Why the information is being released and how it will be used
5. Duration: How long the permission remains valid
6. Consent Statement: Clear statement of permission being granted
1. Third Party Authorization: Additional permissions required when information relates to or affects third parties
2. Special Category Data: Additional permissions for sensitive data such as medical, religious, or other sensitive information
3. Representative Authority: Details of legal representative's authority when form is signed by someone other than the data subject
1. Identity Verification Documents: Copies of documents used to verify the identity of the person giving permission
2. Detailed Information List: Itemized list of specific information to be released when too detailed for main form
3. Supporting Documentation: Any additional documents supporting the authorization (e.g., power of attorney)
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