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Universal Medical Release Form
"I need a Universal Medical Release Form to authorize my GP to share my complete medical history with my new specialist consultant at London Bridge Hospital, with the authorization valid from January 2025 to December 2025."
1. Patient Information: Full legal name, date of birth, address, NHS number, contact details
2. Authorization Statement: Clear statement of consent for release of medical information
3. Scope of Release: Specific medical information authorized for release
4. Duration of Authorization: Time period for which the authorization is valid
5. Recipient Information: Details of authorized recipients of the medical information
6. Patient Rights Statement: Information about right to revoke and data protection rights
7. Signature Block: Patient signature, date, witness requirements
1. Mental Capacity Declaration: Section to be included when release is signed by someone other than patient due to mental capacity issues or appointed representation
2. Specific Exclusions: Section for listing information specifically excluded from the release authorization
3. Emergency Contact: Section for additional contact points when alternative contacts are needed
1. Schedule 1 - Specific Records: Detailed list of specific medical records to be released
2. Schedule 2 - Authorized Recipients: Detailed list of all authorized recipients and their access levels
3. Appendix A - Patient Rights: Detailed explanation of patient rights under data protection laws
4. Appendix B - Proof of Identity: Requirements for identity verification
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