Patient Disclosure Authorization Form

Patient Disclosure Authorization Form Template for South Africa

A comprehensive legal document governed by South African law that enables patients to authorize the disclosure of their medical information to specified parties. This form complies with the Protection of Personal Information Act (POPIA) and the National Health Act, ensuring proper handling of sensitive health information. It includes detailed sections on patient identification, scope of authorization, recipient details, duration of validity, and patient rights regarding their medical information. The document serves as a critical tool for maintaining patient privacy while facilitating necessary information sharing in the healthcare system.

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

Download a Standard Patient Disclosure Authorization Form

Download a South Africa-compliant Patient Disclosure Authorization Form or see .

Get template free

Review your own Patient Disclosure Authorization Form

Let ��Ƶ identify missing terms, unusual language, compliance issues and more.

Your data doesn't train Genie's AI

You keep IP ownership of your docs

4.6 / 5

4.8 / 5

What is a Patient Disclosure Authorization Form?

The Patient Disclosure Authorization Form is a crucial document required in South African healthcare settings whenever patient medical information needs to be shared with third parties. This form ensures compliance with the Protection of Personal Information Act (POPIA), the National Health Act, and other relevant healthcare privacy regulations. It is used when patients need to authorize the release of their medical records to insurance companies, other healthcare providers, legal representatives, or other authorized parties. The document includes comprehensive details about what information can be shared, with whom, for what purpose, and for how long the authorization remains valid. It serves as a legal safeguard for both healthcare providers and patients, ensuring transparent and authorized sharing of sensitive medical information while protecting patient privacy rights.

What sections should be included in a Patient Disclosure Authorization Form?

1. Patient Information: Patient's full details including full name, ID number, date of birth, contact information, and medical record number

2. Healthcare Provider Information: Details of the healthcare facility/provider authorized to disclose information

3. Purpose of Disclosure: Clear statement of the purpose(s) for which the medical information may be disclosed

4. Information to be Disclosed: Specific description of what medical information is authorized for disclosure, including date ranges

5. Authorized Recipients: Identity and contact details of persons/entities authorized to receive the information

6. Duration of Authorization: Validity period of the authorization and expiration date

7. Patient Rights: Statement of patient's rights regarding revoking authorization and restrictions on re-disclosure

8. Signatures and Declarations: Formal authorization signatures, including patient/legal representative and date

What sections are optional to include in a Patient Disclosure Authorization Form?

1. Electronic Communication Consent: Additional authorization for electronic transmission of medical information, used when digital sharing is anticipated

2. Legal Representative Authorization: Required when someone other than the patient is providing authorization, including proof of authority

3. Specific Exclusions: Section detailing any specific information the patient does not want disclosed

4. International Transfer Consent: Required when medical information may be transferred across borders

5. Translation Declaration: Used when the form has been explained in another language to the patient

6. Mental Health Records: Special authorization section for mental health records, which require additional protection

7. HIV/AIDS Information: Specific authorization for HIV/AIDS-related information disclosure, requiring separate consent

What schedules should be included in a Patient Disclosure Authorization Form?

1. Schedule A: Types of Medical Information: Detailed checklist of specific medical information categories that may be disclosed

2. Schedule B: Authorized Recipients List: Comprehensive list of all authorized recipients and their contact details when multiple parties are involved

3. Schedule C: Fee Schedule: If applicable, costs associated with copying and transmitting medical records

4. Appendix 1: Revocation Form: Template form for revoking authorization if patient chooses to do so

5. Appendix 2: Glossary of Terms: Definitions of medical and legal terms used in the authorization form

Authors

Alex Denne

Head of Growth (Open Source Law) @ ��Ƶ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents

Cost

Free to use

Find the exact document you need

No matches found.

Photo Release For Social (Media)

A South African law-compliant agreement authorizing the use of photographs on social media platforms while ensuring POPIA compliance and protecting all parties' rights.

������Ƶ

How Cambridge United Uses ������Ƶ to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Patient Disclosure Authorization Form

Review your own Patient Disclosure Authorization Form

What is a Patient Disclosure Authorization Form?

What sections should be included in a Patient Disclosure Authorization Form?

What sections are optional to include in a Patient Disclosure Authorization Form?

What schedules should be included in a Patient Disclosure Authorization Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Photo Release For Social (Media)

Permission To Release Medical Information Form

Standard Consent Form For Release Of Personal Information

Consent Form For Release Of Information

Patient Release Form

Consent For Medical Records Release Form

Release Of Health Information Form

Doctor Release Form To Return To Work

Release Waiver Agreement

Consent To Disclose Medical Information

Consent Form To Disclose Medical Information

Consent Form For Social (Media)

3rd Party Release Form

Student Release Form

Promissory Note Release

Minor Release Form

General Authorization For Release Of Information

Estate Executor Release Form

Consent To Disclose Personal Health Information Form

Authorization To Release Medical Information To Family Members

Audio Release Form

Medical Treatment Authorization And Consent Form

Release Of Information Form Mental Health

Medical Treatment Release Form

Key Release Form

Paycheck Release Form

Medical Records Form

Participation Waiver Form

Consent To Share Information

Reference Release Authorization Form

Printing Release Form

Personal Release And Consent Form

Online Photo Consent Form

Minor Consent To Treat Form

Employment Background Check Consent Form

Employee Key Release Form

Video Consent And Release Form

Temporary Guardian Medical Release Form

Simple Release Form

�ұ�Ծ���’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Use Cases

Generate Legal Docs Free

��Ƶ

How Cambridge United Uses ��Ƶ to Speed Up Player Signings and Slash Legal Costs

�ұ�Ծ��’s Security Promise