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Simple Medical Release Form
"I need a Simple Medical Release Form that allows my GP to share my complete medical history with my insurance provider for the period January 2025 to December 2025, ensuring compliance with UK GDPR requirements."
1. Patient Information: Full name, date of birth, address, contact details, NHS number
2. Healthcare Provider Details: Name and address of medical facility/provider releasing information
3. Scope of Release: Specific information being authorized for release
4. Authorization Statement: Clear consent statement for information release
5. Duration of Authorization: Time period for which the release is valid
6. Signature Block: Patient signature, date, witness signature if required
1. Third Party Authorization: Additional section for when information is to be released to someone other than the patient
2. Mental Capacity Statement: Declaration section regarding patient's capacity to consent and details of authorized representative if applicable
3. Specific Exclusions: Section detailing any information explicitly excluded from the release authorization
1. Identity Verification Documents: Schedule listing acceptable identification documents provided by the patient
2. Specific Records Schedule: Detailed itemization of specific medical records authorized for release
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