The Authorization To Disclose Health Information Form is a crucial document used in Australian healthcare settings to ensure compliance with privacy laws and protect patient rights while facilitating necessary information sharing. This form is required whenever protected health information needs to be shared between healthcare providers, organizations, or other authorized parties. It includes specific sections for patient identification, details of the information to be disclosed, recipient information, purpose of disclosure, and duration of authorization. The document must comply with the Privacy Act 1988 (Cth), relevant state health records legislation, and healthcare privacy principles. It is particularly important in cases involving ongoing care, specialist referrals, insurance claims, legal proceedings, or research purposes, where proper authorization for information sharing is essential.

1. Patient Information: Patient's full legal name, date of birth, address, contact details, and any relevant identification numbers (e.g., Medicare number)

2. Healthcare Provider Details: Information about the healthcare provider/organization authorized to release the information, including name, address, and contact details

3. Recipient Information: Details of the person or organization authorized to receive the health information, including name, address, and contact information

4. Information to be Disclosed: Specific description of the health information authorized for release, including date ranges and types of records

5. Purpose of Disclosure: Statement of the reason(s) for requesting the disclosure of health information

6. Duration of Authorization: Specification of how long the authorization remains valid, including start and end dates

7. Rights and Notifications: Statement of patient's rights regarding the authorization, including right to revoke and any limitations

8. Privacy Notice: Mandatory privacy notice as required by Australian privacy laws, including how information will be handled

9. Authorization Statement and Signature: Formal authorization statement, signature lines for patient or authorized representative, and date