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Authorisation For Release Of Protected Health Information Phi
"I need an Authorisation For Release Of Protected Health Information PHI that allows my specialist at London Bridge Hospital to share my complete medical history with a research team at Oxford University for a clinical trial starting in March 2025, with the authorization valid for 12 months."
1. Patient Information: Full details of the patient including name, date of birth, address, and NHS number
2. Authorization Statement: Clear statement of consent for information release in accordance with UK GDPR and Data Protection Act 2018
3. Information to be Released: Specific description of what health information is authorized for release, following data minimization principles
4. Purpose of Disclosure: Stated purpose for which the information will be used, ensuring purpose limitation compliance
5. Recipient Information: Details of who is authorized to receive the information and their role
6. Duration of Authorization: Validity period of the authorization and expiry date
7. Rights and Revocation: Statement of patient's rights and how to revoke authorization
8. Signature Section: Space for patient or authorized representative signature, date, and witness if required
1. Mental Capacity Declaration: Required when patient lacks capacity to consent, in accordance with Mental Capacity Act 2005
2. Specific Exclusions: List of information specifically not to be shared or disclosed
3. Third Party Authorization: Additional authorization for sharing with multiple recipients or organizations
4. Special Category Data Consent: Explicit consent for processing special category health data under UK GDPR Article 9
1. Schedule 1 - Identity Verification Documents: Copies of documents used to verify patient identity and confirm authority to request information
2. Schedule 2 - Power of Attorney Documentation: When applicable, proof of legal authority to act on patient's behalf
3. Schedule 3 - Specific Records List: Detailed inventory of specific records to be released, including date ranges and types of information
4. Schedule 4 - Privacy Notice: Information about how the released data will be processed and protected by the recipient
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