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1. Date and Place: Current date and location where the letter is being executed
2. Patient Information: Full legal name, date of birth, contact details, and medical record number/patient ID of the person whose medical information is to be released
3. Healthcare Provider Information: Name and address of the healthcare facility/provider currently holding the medical records
4. Recipient Information: Name and details of the person/entity authorized to receive the medical information
5. Scope of Authorization: Specific description of medical information to be released (e.g., complete medical record, specific date range, particular condition)
6. Duration of Authorization: Clear statement of how long the authorization remains valid
7. Purpose of Disclosure: Stated purpose for which the medical information is being requested
8. Patient Declaration: Statement confirming voluntary nature of authorization and understanding of rights
9. Signature Block: Space for patient's signature, date, and witness signatures if required
1. Emergency Contact Information: Include when the authorization needs to specify alternative contact person in emergency situations
2. Special Instructions: Any specific handling instructions or restrictions on the use of the medical information
3. Revocation Rights: Optional detailed explanation of the right to revoke authorization and process for doing so
4. Translation Declaration: Include when the letter needs to be in multiple languages or when patient's primary language is not English
5. Digital Communication Consent: Include when medical records may be shared through electronic means
1. Schedule A - Specific Medical Records List: Detailed list of specific medical records being authorized for release, with dates and departments
2. Schedule B - Identification Documents: Copies of required identification documents of the patient and/or authorized recipient
3. Schedule C - Special Conditions: Any special conditions or restrictions on the use or further disclosure of the medical information
Protected Health Information
Medical Records
Healthcare Provider
Authorized Recipient
Authorization Period
Confidential Information
Electronic Health Records
Medical Facility
Patient Identification
Disclosure
Legal Representative
Medical Information
Personal Data
Sensitive Personal Information
Healthcare Treatment
Medical History
Clinical Documentation
Authorization Scope
Revocation
Third Party
Data Privacy
Witness
Digital Records
Consent
Healthcare
Medical Services
Hospital Administration
Insurance
Legal Services
Medical Research
Healthcare Technology
Pharmaceutical
Clinical Trials
Medical Education
Medical Records
Legal & Compliance
Patient Services
Clinical Administration
Healthcare Operations
Risk Management
Privacy & Security
Customer Relations
Documentation
Insurance Coordination
Medical Records Officer
Healthcare Administrator
Legal Compliance Officer
Medical Director
Privacy Officer
Clinical Documentation Specialist
Hospital Administrator
Medical Secretary
Healthcare Legal Counsel
Patient Relations Manager
Insurance Claims Coordinator
Medical Research Coordinator
Clinical Trial Administrator
Healthcare Data Manager
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