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Medical Information Request Form Template
I need a Medical Information Request Form Template for our hospital's research department that allows us to request patient data for a clinical trial starting in March 2025, ensuring GDPR compliance and including specific consent mechanisms for research purposes.
1. Patient Information: Basic identifying details including name, date of birth, NHS number, contact information and address
2. Requestor Details: Information about the person making the request, including full name, contact details and relationship to patient if not the patient themselves
3. Purpose of Request: Clear statement of the specific reason for requesting medical information, including intended use
4. Information Requested: Detailed specification of which medical information is being requested, including date ranges if applicable
5. Consent Declaration: Express consent section for information release, including data protection acknowledgments and GDPR compliance statements
6. Identity Verification: Requirements for proving identity and list of acceptable documentation
1. Third Party Authorization: Additional section for when medical information is to be released to someone other than the patient, including legal authority verification
2. Urgent Request Section: Special section for expedited processing requests, including justification for urgency
3. Fee Information: Details of any applicable charges and payment methods for requests falling outside of free access rights
1. Schedule 1 - Identity Verification Requirements: Comprehensive list of acceptable ID documents and specific requirements for verification
2. Schedule 2 - Fee Schedule: Detailed breakdown of potential charges for different types of requests and circumstances
3. Schedule 3 - Authority Forms: Standard templates for third-party authorization and power of attorney confirmation
4. Schedule 4 - Privacy Notice: Detailed information about how the provided information will be used, stored, protected and processed in compliance with GDPR
Authors
Authorized Representative
Capacity
Confidential Information
Consent
Data Controller
Data Protection Legislation
Data Subject
Healthcare Provider
Health Record
Medical Information
Medical Records
NHS Number
Patient
Personal Data
Processing
Registered Medical Practitioner
Requestor
Sensitive Personal Data
Special Category Data
Subject Access Request
Third Party
Confidentiality
Consent
Access Rights
Identity Verification
Information Use
Processing Time
Fees and Charges
Third Party Disclosure
Record Retention
Information Accuracy
Patient Rights
Emergency Access
Complaints Procedure
Information Security
Records Management
Authorized Representatives
Capacity and Authority
Purpose Limitation
Privacy Notice
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