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Authorisation To Use And Disclose Protected Health Information Form
"I need an Authorization To Use And Disclose Protected Health Information Form for a medical research study running from March 2025 to December 2025, specifically allowing the sharing of patient data with three university research departments while excluding mental health records."
1. Patient Information: Full name, date of birth, address, contact details, NHS number
2. Authorization Statement: Clear statement of consent to use and disclose health information
3. Information to be Disclosed: Specific description of what health information can be shared
4. Purpose of Disclosure: Reason for sharing the health information
5. Recipients: Who is authorized to receive the information
6. Duration: How long the authorization remains valid
7. Signature Block: Patient signature, date, witness if required
1. Representative Authorization: Section for cases where someone other than patient is authorizing disclosure, required when patient lacks capacity or has appointed representative
2. Specific Exclusions: Section detailing any information that should not be shared, used when patient wants to restrict certain information
3. Electronic Communications Consent: Additional consent section for electronic transmission of information, required when electronic sharing methods will be used
1. Privacy Notice: Detailed information about how data will be processed and protected
2. Rights Information Sheet: Summary of patient's rights regarding their health information
3. Revocation Form: Form to withdraw authorization if needed
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