The Medical Release of Information Form is a critical document used in Nigerian healthcare settings when there is a need to share patient medical information with authorized third parties. This form is essential for compliance with the National Health Act 2014 and the Nigeria Data Protection Regulation (NDPR) 2019, which govern the confidentiality and transfer of medical records. It is typically required when patients need their medical information shared with other healthcare providers, insurance companies, legal representatives, or other authorized parties. The form ensures that any release of medical information is properly documented, authorized, and limited to the specific information needed for the stated purpose. It includes comprehensive patient identification, details of the requesting party, specific information to be released, and clear authorization parameters.

1. Patient Information: Complete identification details of the patient including full name, date of birth, address, contact information, and medical record number

2. Healthcare Provider Information: Details of the healthcare provider/facility currently holding the medical records, including name, address, and contact information

3. Recipient Information: Complete details of the person or entity to whom the medical information will be released, including name, address, and contact information

4. Information to be Released: Specific description of what medical information is authorized for release, including date ranges and types of records

5. Purpose of Disclosure: Clear statement of the reason for releasing the medical information

6. Duration of Authorization: Specific timeframe for which the authorization is valid

7. Rights and Notifications: Statement of patient rights regarding the release of information, including right to revoke authorization

8. Authorization Statement: Formal declaration of consent to release the specified medical information

9. Signature Block: Space for patient or authorized representative signature, date, and witness signature if required