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1. Date and Place: Current date and location where the letter is being executed
2. Healthcare Provider Details: Full name and address of the healthcare facility or provider holding the medical records
3. Patient Information: Complete identification details of the patient including full name, Emirates ID number, date of birth, and medical record number if known
4. Authorized Person Details: Full identification details of the person being authorized to collect records, including name, Emirates ID number, and relationship to patient
5. Scope of Authorization: Specific details of what medical records are being requested and for what time period
6. Purpose of Request: Clear statement of why the medical records are being requested
7. Duration of Authorization: Validity period of the authorization
8. Patient Declaration: Statement confirming the voluntary nature of authorization and understanding of privacy implications
9. Signature Block: Space for patient's signature, witness signature if required, and date of signing
1. Urgency Statement: To be included when records are needed urgently, specifying the reasoning and timeframe
2. Third Party Authorization: Additional section when records are to be released to a third party (e.g., insurance company or legal representative)
3. Special Instructions: Any specific instructions regarding format of records (digital/physical) or delivery method
4. Previous Record Requests: Reference to any previous requests made, if relevant
5. Language Preference: Specification of preferred language for medical records if translation is needed
1. Identification Documents: Copies of Emirates ID of both patient and authorized person
2. Proof of Relationship: If authorized person is a family member, relevant documentation proving relationship
3. Previous Medical Record Numbers: List of relevant medical record numbers or visit dates if multiple facilities are involved
4. Healthcare Provider Forms: Any specific forms required by the healthcare provider for record release
Emirates ID
Healthcare Provider
Medical Records
Patient
Medical Record Number
Authorization Period
Health Information
Healthcare Facility
Medical Reports
Treatment History
Confidential Information
Release Date
Request Purpose
Healthcare Authority
Personal Data
Medical Documentation
Patient File
Authorization Scope
Identity Documents
Data Protection
Confidentiality
Duration
Identity Verification
Record Access
Purpose Declaration
Patient Rights
Consent
Release Authorization
Third Party Access
Validity Period
Revocation Rights
Governing Law
Healthcare Provider Obligations
Record Specifications
Privacy Protection
Authentication
Healthcare
Insurance
Legal Services
Healthcare Administration
Medical Records Management
Patient Services
Healthcare Compliance
Medical Tourism
Healthcare Technology
Healthcare Consulting
Medical Records
Legal
Compliance
Patient Relations
Healthcare Administration
Insurance Processing
Clinical Documentation
Privacy and Data Protection
Operations
Customer Service
Risk Management
Medical Records Officer
Healthcare Administrator
Compliance Officer
Legal Counsel
Insurance Claims Manager
Patient Relations Manager
Healthcare Facility Director
Medical Secretary
Clinical Documentation Specialist
Privacy Officer
Healthcare Operations Manager
Medical Records Coordinator
Patient Services Representative
Healthcare Compliance Manager
Medical Legal Advisor
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