Medical Release Physician's Statement Form Template for England and Wales

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Key Requirements PROMPT example:

Medical Release Physician's Statement Form

"I need a Medical Release Physician's Statement Form for my insurance company that covers my recent knee surgery and ongoing physiotherapy treatment, including a detailed assessment of my expected recovery timeline and ability to return to work by March 2025."

Document background

The Medical Release Physician's Statement Form is essential in situations where formal medical verification is required by third parties while maintaining compliance with UK healthcare regulations. This document is commonly used for insurance claims, employment matters, legal proceedings, or benefit applications. It includes detailed medical assessments, patient consent mechanisms, and data protection notices as required by UK law. The form ensures that sensitive medical information is shared appropriately and securely, with full respect for patient privacy rights and in accordance with the UK GDPR and medical practice standards.

Suggested Sections

1. Patient Information: Full name, date of birth, address, contact details, and any relevant identification numbers

2. Physician Information: Name, medical license number, practice details, and professional contact information

3. Medical Condition Assessment: Current diagnosis, medical condition details, and professional medical opinion

4. Patient Consent Declaration: Express authorization to release information and acknowledgment of data usage

5. Data Protection Notice: Information about how medical data will be used, stored, protected and shared in accordance with UK GDPR

Optional Sections

1. Treatment History: Detailed medical history and treatment record when long-term medical context is relevant

2. Capacity Assessment: Assessment of patient's mental capacity to provide consent, required when capacity might be in question

3. Third Party Authorization: Authorization details when medical information is to be released to someone other than the patient

Suggested Schedules

1. Medical Records: Copies of relevant medical documentation and test results

2. Consent Forms: Additional detailed consent documentation and authorizations

3. Information Sharing Agreement: Detailed protocol for information sharing between relevant parties

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

Authorised Person
Clinical Information
Confidential Information
Consent
Data Protection Laws
Healthcare Provider
Medical Condition
Medical History
Medical Records
Patient
Personal Data
Physician
Protected Health Information
Recipient
Releasing Party
Sensitive Personal Data
Statement
Treatment
Third Party

Clauses

Relevant Industries

Relevant Teams

Relevant Roles

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Let's create your Medical Release Physician's Statement Form

Authors

Alex Denne

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