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1. Patient Information: Complete identification details of the patient including name, date of birth, address, contact information, and any relevant patient ID numbers
2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records, including name, address, and contact information
3. Recipient Information: Details of the person/entity to whom the medical information is to be disclosed, including name, address, and contact information
4. Information to be Disclosed: Specific description of medical information authorized for disclosure, including type of records, date range, and any specific conditions or treatments
5. Purpose of Disclosure: Clear statement of the reason(s) for requesting the medical information disclosure
6. Duration of Authorization: Specific time period for which the authorization is valid
7. Rights and Notices: Statement of patient's rights including right to revoke authorization and any limitations on redisclosure
8. Signatures: Space for required signatures including patient or legal representative, date, and witness if required
1. Special Categories of Information: Additional authorization for sensitive information such as HIV status, mental health records, or genetic information - used when such specific records are involved
2. Electronic Transmission Authorization: Specific permission for electronic transmission of records - used when digital transfer is anticipated
3. Legal Representative Authorization: Additional section when authorization is given by someone other than the patient (guardian, power of attorney, etc.)
4. Payment Information: Details about any fees associated with the records transfer - used when applicable charges exist
5. Emergency Contact Information: Additional contact details for urgent situations - used in cases where immediate communication might be necessary
1. Schedule A - Detailed Record List: Comprehensive list of specific medical records being authorized for disclosure
2. Schedule B - Authorized Recipients List: Detailed list of all authorized recipients when multiple parties are involved
3. Appendix 1 - Patient Rights Information: Detailed explanation of patient rights regarding medical information disclosure under Indian law
4. Appendix 2 - Privacy Notice: Detailed privacy notice explaining how the disclosed information will be protected and used
Healthcare
Insurance
Medical Research
Pharmaceuticals
Legal Services
Education (Medical Institutions)
Occupational Health
Clinical Trials
Healthcare Technology
Public Health
Legal
Compliance
Medical Records
Patient Services
Risk Management
Data Protection
Clinical Administration
Quality Assurance
Insurance Processing
Healthcare Operations
Medical Records Officer
Privacy Officer
Compliance Manager
Healthcare Administrator
Medical Director
Legal Counsel
Insurance Claims Manager
Clinical Research Coordinator
Hospital Administrator
Data Protection Officer
Patient Services Coordinator
Medical Secretary
Healthcare Compliance Officer
Risk Management Director
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