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Authorisation To Use And Disclose Protected Health Information Form Template for England and Wales

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Key Requirements PROMPT example:

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."

Document background
The Authorization To Use And Disclose Protected Health Information Form is a crucial document required under English and Welsh law when healthcare providers need to share patient information beyond direct care purposes. This form ensures compliance with the UK Data Protection Act 2018, UK GDPR, and healthcare-specific regulations. It should be used whenever protected health information needs to be shared with third parties, such as for research, insurance purposes, or with other healthcare providers outside the direct care team. The form includes specific details about what information can be shared, the duration of the authorization, and the intended recipients, while protecting patients' privacy rights.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Authors

Alex Denne

Head of Growth (Open Source Law) @ tiktok³ÉÈ˰æ | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Relevant legal definitions

























Clauses




















Industries

UK Data Protection Act 2018: Primary UK legislation governing the processing of personal data, including health information. Implements and supplements the UK GDPR.

UK GDPR: Post-Brexit version of the EU GDPR, setting out fundamental principles for data protection including lawfulness, fairness, transparency, purpose limitation, and data minimization.

Access to Health Records Act 1990: Legislation providing individuals with the right to access health records, particularly relevant for deceased patients' records.

Mental Capacity Act 2005: Legislation governing decision-making for individuals who lack capacity, including provisions for health information disclosure.

Health and Social Care Act 2012: Framework legislation for health service delivery in England, including provisions for information governance and sharing.

Common Law Duty of Confidentiality: Legal principle requiring healthcare professionals to keep patient information confidential unless there is a lawful basis for disclosure.

Caldicott Principles: Set of principles governing the handling of patient-identifiable information in the NHS, including justification for data use and minimum necessary access.

NHS Act 2006: Legislative framework for the NHS, including provisions for handling patient information and confidentiality.

GMC Guidance on Confidentiality: Professional guidelines from the General Medical Council on managing patient confidentiality and information disclosure.

BMA Guidelines: British Medical Association's professional guidance on handling patient information and consent for disclosure.

NHS Digital Data Security and Protection Toolkit: Framework of standards for handling health and care information, including requirements for security and protection of patient data.

Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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