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Authorisation For Disclosure
"I need an Authorisation For Disclosure document to allow my medical records to be shared from London Bridge Hospital to my new specialist at Mayo Clinic for a period of 6 months starting from January 2025, with specific restrictions on sharing with third parties."
1. Details of Authorising Party: Full name, address, and any relevant identification details of the person/entity giving authorization
2. Details of Recipient: Entity or person authorized to receive the information, including full contact details
3. Scope of Disclosure: Specific description of information to be disclosed, including nature and extent of information
4. Purpose of Disclosure: Clear statement of why the disclosure is being authorized and how information will be used
5. Duration: Period for which the authorization is valid, including start and end dates if applicable
6. Data Protection Statement: Statement confirming compliance with UK GDPR and Data Protection Act 2018
7. Signature Block: Space for date and signature of authorizing party
1. Third Party Recipients: Additional authorized recipients, used when information may be shared beyond primary recipient
2. Restrictions: Specific limitations on use of disclosed information, used when special handling is required
3. Revocation Terms: Conditions under which authorization can be withdrawn, used for longer-term authorizations
4. Confidentiality Requirements: Specific confidentiality obligations for recipients, used when handling sensitive information
5. Legal Rights Statement: Statement of legal rights under relevant legislation, used when complex legal framework applies
1. Schedule 1 - List of Specific Documents: Detailed inventory of documents/information covered by authorization
2. Schedule 2 - Identity Verification: Copies of identification documents of authorizing party
3. Schedule 3 - Supporting Documentation: Any additional documents supporting the need for disclosure
4. Schedule 4 - Relevant Legislation: List of applicable laws and regulations governing the disclosure
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