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1. Parties: Identifies the patient (authorizing party) and the healthcare provider/facility that is authorized to release the information
2. Background: Brief context explaining the purpose of the authorization and its compliance with privacy laws
3. Definitions: Clear definitions of key terms such as 'Medical Information', 'Healthcare Provider', 'Authorized Family Members', and 'Protected Health Information'
4. Authorization Grant: Explicit authorization for the release of specified medical information to named family members
5. Scope of Authorization: Detailed description of what medical information may be released, including any specific limitations or restrictions
6. Duration of Authorization: Specifies how long the authorization remains valid
7. Rights of Revocation: Explains the patient's right to revoke the authorization and the process for doing so
8. Privacy Notice: Statement regarding privacy laws and potential re-disclosure of information
9. Signatures: Space for patient signature, date, and witness signature if required
1. Emergency Contact Provisions: Additional provisions for emergency situations where immediate information sharing may be necessary
2. Digital Access Authorization: Specific provisions for electronic access to medical records, if applicable
3. Interstate Information Sharing: Additional provisions for cases where information may need to be shared across state borders
4. Capacity Declaration: Section to be included when the authorization is being made by a legal guardian or power of attorney
5. Special Conditions: Any specific conditions or restrictions on the sharing of sensitive information (e.g., mental health, genetic information)
1. Schedule A - Authorized Family Members: Detailed list of authorized family members including their full names, relationships, contact information, and specific access levels
2. Schedule B - Types of Medical Information: Comprehensive list of the types of medical information that may be released (e.g., test results, diagnoses, treatment plans)
3. Schedule C - Healthcare Providers: List of specific healthcare providers or facilities authorized to release information
4. Appendix 1 - Revocation Form: Standard form for revoking the authorization if needed
Healthcare Provider
Medical Information
Protected Health Information
Health Record
Personal Information
Sensitive Information
Authorization Period
Healthcare Facility
Medical Treatment
Disclosure
Revocation
Emergency Contact
Treating Practitioner
Confidential Information
Next of Kin
Legal Representative
Clinical Records
Test Results
Treatment Plan
Healthcare Services
Medical History
Digital Health Record
Authorized Representative
Capacity
Privacy Protection
Information Access
Consent
Confidentiality
Duration and Termination
Revocation Rights
Emergency Provisions
Liability and Indemnification
Compliance
Information Security
Record Keeping
Disclosure Limitations
Rights and Obligations
Witness Requirements
Electronic Access
Dispute Resolution
Governing Law
Severability
Amendments
Healthcare
Medical Services
Aged Care
Mental Health Services
Allied Health Services
Hospital Administration
Medical Insurance
Healthcare Technology
Disability Services
Palliative Care
Medical Records
Compliance
Legal
Patient Services
Health Information Management
Risk Management
Clinical Administration
Privacy and Data Protection
Patient Relations
Administrative Services
Medical Records Officer
Privacy Officer
Healthcare Administrator
Clinical Director
Medical Practice Manager
Compliance Officer
Patient Services Coordinator
Health Information Manager
Legal Counsel
Risk Management Officer
Healthcare Provider
Nurse Manager
Patient Rights Advocate
Medical Secretary
Practice Administrator
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