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

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.

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