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1. Title and Date: Clear identification of the document as an Authorization for Release of Information Form and the date of execution
2. Authorizing Party Details: Full name, identification number (IC/passport), and contact details of the person authorizing the release of information
3. Recipient Party Details: Name and details of the organization/person authorized to receive the information
4. Information Holder Details: Name and details of the organization/person currently holding the information who is authorized to release it
5. Scope of Authorization: Specific description of what information is authorized to be released
6. Purpose of Disclosure: Clear statement of why the information is being released and how it will be used
7. Duration of Authorization: The period for which the authorization remains valid
8. Rights and Revocation: Statement of the authorizing party's rights including the right to revoke the authorization
9. Signature Block: Space for signatures of the authorizing party, witness(es), and date of signing
1. Medical Information Specifics: Additional section when the authorization involves medical records, including specific health information to be released and relevant healthcare providers
2. Financial Information Details: Additional section when the authorization involves financial records, specifying account numbers or types of financial information
3. Third Party Authorization: Section needed when the authorizing party is acting on behalf of another person (e.g., parent for child, guardian for ward)
4. Confidentiality Agreement: Additional provisions regarding confidentiality obligations of the recipient when handling sensitive information
5. Electronic Transmission Authorization: Specific authorization for electronic transmission of information when applicable
1. Schedule A - Types of Information: Detailed list of specific information types authorized for release, particularly useful for complex authorizations involving multiple categories of information
2. Schedule B - Authorized Recipients List: List of all authorized recipients when multiple parties are involved
3. Appendix 1 - Identity Verification Documents: Copies of identity documents required to verify the authorizing party's identity
4. Appendix 2 - Supporting Documentation: Any additional documents supporting the authorization (e.g., power of attorney, court orders)
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