Authorization To Release Information Template for Belgium

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Key Requirements PROMPT example:

Authorization To Release Information

"I need an Authorization to Release Information document under Belgian law for my medical clinic in Brussels, allowing us to share patient records with specialist consultants for a research project running from March 2025 to December 2025, with specific GDPR compliance measures included."

Document background

The Authorization To Release Information document is essential in Belgian business and administrative practices where controlled information sharing is required while maintaining compliance with strict privacy laws. This document type is commonly used when an individual or organization needs to grant another party access to their personal, medical, financial, or other confidential information. The authorization must comply with the Belgian Data Protection Act and GDPR, requiring specific elements such as explicit consent, purpose limitation, and data subject rights. It's particularly relevant in situations involving healthcare providers, financial institutions, or government agencies, where formal permission is needed to share protected information. The document must be available in the official languages of Belgium (Dutch, French, and German) depending on the region of use, and should include clear provisions for both physical and electronic information sharing.

Suggested Sections

1. Authorizing Party Details: Full name, address, and identification details of the person giving authorization

2. Recipient Organization Details: Name and details of the organization/entity authorized to receive the information

3. Purpose of Authorization: Clear statement of why the information is being released and how it will be used

4. Information to be Released: Specific description of what information is authorized for release

5. Duration of Authorization: Time period for which the authorization is valid

6. Data Protection Statement: Statement about how the information will be protected and GDPR compliance

7. Revocation Rights: Explanation of the right to withdraw authorization and how to do so

8. Signature Block: Space for date, signature, and witness if required

Optional Sections

1. Medical Information Specifics: Additional section when authorization involves medical records, including specific health data categories

2. Third Party Recipients: Section needed when information may be shared with additional parties beyond the primary recipient

3. International Transfer Notice: Required when information may be transferred outside the EU/EEA

4. Electronic Processing Consent: Additional consent for digital processing and storage of information

5. Language Declaration: Statement confirming the language choice for the document when used in different Belgian linguistic regions

Suggested Schedules

1. Information Checklist: Detailed checklist of specific documents/information covered by the authorization

2. Recipients List: Complete list of all authorized recipients if multiple parties are involved

3. Privacy Notice: Detailed privacy notice explaining how the information will be handled and protected

4. Revocation Form: Template form for withdrawing authorization if needed in the future

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

alex.den.21@genieai.co

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Find the exact document you need

Authorisation Form

A Belgian-law compliant document that formally grants specific powers or permissions from an authorizing party to an authorized representative.

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Authors

Alex Denne

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