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Authorisation For Disclosure Of Protected Health Information Form
"I need an Authorisation For Disclosure Of Protected Health Information Form for a clinical trial starting in March 2025, which will allow our research institution to access patient records from multiple NHS trusts while ensuring GDPR compliance and including specific provisions for data anonymization."
1. Patient Information: Full name, date of birth, address, NHS number, contact details
2. Healthcare Provider Details: Name and address of the healthcare provider holding the information
3. Information to be Disclosed: Specific description of medical information to be shared
4. Purpose of Disclosure: Reason for requesting information disclosure
5. Recipient Details: Who will receive the information
6. Duration of Authorization: Time period for which authorization is valid
7. Rights Statement: Patient's rights including right to revoke authorization
1. Representative Authorization: Additional section required when someone other than the patient is authorizing the disclosure (e.g., legal representative or next of kin)
2. Specific Exclusions: Section for specifying particular information that the patient explicitly does not want shared
3. Emergency Contact: Section for alternative contact details when an additional point of contact is needed
1. Identity Verification Requirements: List of acceptable identification documents and verification process
2. Fee Schedule: Schedule detailing any applicable costs associated with information provision
3. Privacy Notice: Detailed information about data protection rights and processes under UK GDPR and DPA 2018
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