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1. Date and Location: Current date and place of writing the authorization letter
2. Recipient Details: Full name, title, and address of the healthcare facility or organization the letter is addressed to
3. Patient Identification: Full name, date of birth, and relevant identification numbers of the patient giving authorization
4. Doctor Identification: Full name, medical license number, and practice details of the authorized doctor
5. Authorization Statement: Clear and specific statement of what medical actions or access the doctor is being authorized to perform
6. Duration of Authorization: Specific timeframe for which the authorization is valid
7. Patient Consent Declaration: Express statement of consent and understanding of the authorization being given
8. Signature Block: Space for patient signature, date, and witness signature if required
1. Emergency Contact Information: Contact details for emergency situations - include when the authorization covers emergency procedures
2. Medical History Access: Specific authorization for accessing historical medical records - include when historical access is needed
3. Insurance Information: Details of relevant insurance coverage - include when authorization relates to insured procedures
4. Special Conditions: Any specific conditions or limitations on the authorization - include when there are restrictions
5. Third Party Authorization: Authorization for the doctor to share information with specific third parties - include when information sharing is needed
1. List of Authorized Procedures: Detailed list of specific medical procedures being authorized
2. Copy of Patient ID: Attached copy of patient's identification document
3. Medical History Summary: Relevant medical history information pertinent to the authorization
4. Doctor's Credentials: Copies of relevant medical licenses and certifications
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