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Authorisation For Disclosure Of Medical Information
"I need an Authorisation For Disclosure Of Medical Information to allow my insurance company to access my medical records from London Bridge Hospital for the period January 2025 to June 2025, specifically relating to my knee surgery and subsequent physiotherapy."
1. Patient Information: Full name, date of birth, address, NHS number or other relevant identifiers
2. Authorisation Statement: Clear statement of consent for disclosure
3. Scope of Disclosure: Specific information to be disclosed and time period covered
4. Recipient Details: Who is authorized to receive the information
5. Duration of Authorization: How long the authorization remains valid
6. Patient Declaration: Signature and date of authorization
1. Third Party Authorization: Authorization section for when someone other than the patient is providing authorization (used when patient lacks capacity or for minors)
2. Specific Exclusions: Section detailing any specific information that should not be disclosed (used when patient wants to restrict certain information)
3. Purpose of Disclosure: Section specifying the reason for requesting information (used when disclosure is for specific purpose only)
1. Proof of Identity: Copies of identification documents
2. Power of Attorney: If applicable, documentation proving authority to act on patient's behalf
3. Specific Records Request Form: Detailed form listing specific records being requested
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