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1. Date and Location: Current date and place where the authorization letter is being written
2. Authorizer Details: Full legal name, address, date of birth, and health insurance number of the person giving authorization
3. Authorized Person Details: Full legal name, address, and relationship to the authorizer of the person being authorized
4. Authorization Scope: Clear specification of what medical activities are being authorized (picking up prescriptions, accessing medical records, etc.)
5. Duration of Authorization: Specific time period for which the authorization is valid
6. Privacy Consent: GDPR-compliant statement about consent to handle personal medical data
7. Signatures: Space for signatures of both the authorizer and authorized person
1. Emergency Contact Information: Additional contact details for urgent situations - recommended when the authorized person is not a immediate family member
2. Specific Medicine Details: List of specific medications covered by the authorization - useful when authorization is limited to certain prescriptions
3. Healthcare Provider Information: Details of specific doctors or pharmacies where the authorization can be used - necessary when authorization is limited to specific providers
4. Revocation Clause: Specific conditions under which the authorization can be revoked - recommended for long-term authorizations
5. Language Declaration: Statement confirming understanding if either party is not a native German speaker - required when relevant
1. List of Authorized Medications: Detailed list of specific medications covered by the authorization, including dosages and prescription numbers if applicable
2. Copy of Identification Documents: Copies of official ID documents of both the authorizer and authorized person
3. Medical History Summary: Brief relevant medical history if authorization includes access to medical records
4. Healthcare Provider List: List of specific healthcare providers, pharmacies, and facilities where the authorization is valid
Find the document you need
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