Authorization To Release Protected Health Information Form Template for Belgium

Create a bespoke document in minutes, or upload and review your own.

4.6 / 5

4.8 / 5

Let's create your Authorization To Release Protected Health Information Form

1. Select your governing law and document type:

2. Enter your key requirements:

3. Create your document to edit, review or download

Get your first 2 documents free

Your data doesn't train Genie's AI

You keep IP ownership of your information

Key Requirements PROMPT example:

Authorization To Release Protected Health Information Form

"I need an Authorization To Release Protected Health Information Form that allows my hospital to share patient data with a medical research institution in Brussels for a clinical trial running from March 2025 to December 2025, ensuring GDPR compliance and specific consent for genetic data processing."

Document background

The Authorization To Release Protected Health Information Form is a crucial document used in Belgian healthcare settings when patient medical information needs to be shared between healthcare providers or with authorized third parties. This document is essential for compliance with the Belgian Privacy Act, Patient Rights Act, and EU GDPR requirements. It's typically used when patients need to transfer medical records to new healthcare providers, share information with insurance companies, or authorize access for medical research. The form ensures that patients maintain control over their medical information while providing healthcare providers with clear documentation of authorized information sharing. Its structure and content are specifically designed to meet Belgian legal requirements for medical data protection and transfer.

Suggested Sections

1. Patient Information: Complete identification details of the patient including full name, date of birth, address, contact information, and national registry number

2. Healthcare Provider Information: Details of the healthcare provider/institution currently holding the medical records

3. Recipient Information: Information about the person or entity authorized to receive the medical information

4. Information to be Released: Specific description of what medical information is authorized for release, including date ranges and types of records

5. Purpose of Disclosure: Statement of the reason for releasing the medical information

6. Duration of Authorization: Specification of how long the authorization remains valid

7. Rights Statement: Information about the patient's rights under GDPR and Belgian law, including right to revoke authorization

8. Signatures and Date: Space for patient (or legal representative) signature, date, and witness signature if required

Optional Sections

1. Legal Representative Authorization: Required only when someone other than the patient is authorizing the release, including details of their legal authority

2. Specific Consent for Sensitive Information: Additional authorization section for sensitive medical information (mental health, HIV status, genetic information) requiring explicit consent

3. Electronic Transmission Authorization: Specific authorization for electronic transmission of records, if applicable

4. Translation Declaration: Required when the form is provided in multiple languages, confirming the accuracy of translation

Suggested Schedules

1. List of Specific Records: Detailed itemization of specific medical records to be released, allowing for precise selection

2. Fee Schedule: If applicable, breakdown of any administrative fees for record copying and transmission

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

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

Relevant legal definitions

Clauses

Relevant Industries

Healthcare

Insurance

Medical Research

Pharmaceuticals

Elder Care

Mental Healthcare

Public Health

Healthcare Technology

Medical Education

Occupational Health

Relevant Teams

Legal

Compliance

Medical Records

Patient Administration

Data Protection

Healthcare Operations

Quality Assurance

Patient Services

Medical Administration

Information Management

Relevant Roles

Medical Director

Privacy Officer

Healthcare Administrator

Medical Records Manager

Compliance Officer

Legal Counsel

Data Protection Officer

Patient Relations Coordinator

Healthcare Provider

Insurance Claims Processor

Medical Research Coordinator

Clinical Trial Administrator

Medical Secretary

General Practitioner

Medical Specialist

Find the exact document you need

Authorization To Share Medical Information Form

A Belgian-compliant authorization form for sharing medical information, meeting GDPR and local healthcare law requirements.

How Genie AI reduced drafting time by 75% for a legal firm

Let's create your Authorization To Release Protected Health Information Form

Authors

Alex Denne

Find the exact document you need

Authorization To Share Medical Information Form

Authorization To Release Protected Health Information Form

Tenant Release Form

Consent Form For Social (Media)

Authorization To Share Information

Minor Consent To Treat Form

Legal Release Form

Hospital Release Form

Dental Release Form

Actor Release Form

Credit Release Authorization Form

Credit Check Release Form

Towing Release Form

Permission And Medical Release Form

Release And Discharge Letter

Medical Consent Form For Family Members

Basic Photo Release Form

Release And Consent Form

Real Estate Property Release Form

Patient Photo Consent Form

Logo Release Form

Company Release Form

Confidentiality Release Form

Financial Release Form

Release And Authorization Form

Company Release Letter

Employee Consent Form For Photo Use

Film Release Form

Insurance Release Form

Contractors Release Form

Business Release Form

Consent Information Form

Privacy Release Form

Health Information Form

Fund Release Form

Employee Waiver And Release Form

Client Release Form

Claim And Release Form

Release Form

Parental Release Form For Travel

Testimonial Release Form

Standard Release Form

General Release Agreement

Payment Release Form

Deposit Release Form

Receipt And Release Form

Release Of Claims Form

Employee Release Form

Interview Release Form

Consent Form For Video Recording

Release Of Authorization Form

Medical Records Release Form

Medical Consent Form For Minor

Download our whitepaper on the future of AI in Legal

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security

Innovation in privacy:

Want to know more?

Commercial

Employment

IP

Administration

Finance

R&D

Use Cases