Medical Information Disclosure Consent Form for the Netherlands

Medical Information Disclosure Consent Form Template for Netherlands

A comprehensive consent form designed for use in the Netherlands that complies with both EU GDPR and Dutch healthcare legislation, particularly the Medical Treatment Contracts Act (WGBO). This document enables healthcare providers to obtain explicit patient consent for sharing medical information while ensuring compliance with data protection requirements. It includes detailed sections on the scope of information to be shared, intended recipients, duration of consent, and patient rights, while incorporating specific Dutch legal requirements for medical information handling and patient privacy protection.

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What is a Medical Information Disclosure Consent Form?

The Medical Information Disclosure Consent Form is a crucial document required under Dutch law whenever patient medical information needs to be shared with third parties. This form ensures compliance with the EU General Data Protection Regulation (GDPR), the Dutch GDPR Implementation Act (UAVG), and the Medical Treatment Contracts Act (WGBO). It is essential for healthcare providers when seeking patient authorization to share medical records, test results, or treatment information with other healthcare providers, insurance companies, or research institutions. The form must be used to document explicit patient consent before any disclosure of medical information, except in specific emergency situations or where otherwise permitted by law. It includes comprehensive information about the type of medical data being shared, the purpose of sharing, recipient details, and the duration of consent, while clearly outlining patient rights regarding their medical information.

What sections should be included in a Medical Information Disclosure Consent Form?

1. Patient Information: Details of the patient including full name, date of birth, patient ID number, and contact information

2. Healthcare Provider Information: Details of the healthcare provider/institution requesting consent, including name, address, and contact information

3. Purpose of Disclosure: Clear explanation of why the medical information needs to be shared and how it will be used

4. Information to be Disclosed: Specific description of what medical information will be shared (e.g., complete medical record, specific test results, treatment history)

5. Recipients of Information: Details of who will receive the medical information, including names and/or categories of recipients

6. Duration of Consent: Specification of how long the consent will remain valid

7. Patient Rights: Explanation of patient's rights including right to withdraw consent, right to access data, and right to file complaints

8. Declaration of Consent: Formal statement of consent with space for patient signature, date, and witness signature if required

What sections are optional to include in a Medical Information Disclosure Consent Form?

1. Special Categories of Data: Additional section when sensitive information like genetic data, mental health records, or HIV status are involved

2. Minor Patient Provisions: Required when the patient is under 16 years old, including parent/guardian consent requirements

3. Emergency Contact Authorization: Optional section authorizing disclosure to emergency contacts under specific circumstances

4. International Transfer Provisions: Required when medical information may be transferred outside the EU/EEA

5. Digital Communication Consent: Optional section for consent to receive information via email or patient portals

6. Research Use Authorization: Optional section for consent to use medical information in research studies

What schedules should be included in a Medical Information Disclosure Consent Form?

1. Detailed List of Medical Records: Itemized list of specific medical records and information covered by the consent

2. Privacy Notice Summary: Summary of the healthcare provider's privacy policy and data protection measures

3. Patient Rights Guide: Detailed explanation of patient rights under GDPR and Dutch healthcare laws

4. Authorized Recipients List: Complete list of authorized recipients and their contact information

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

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Free to use

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Form Giving Medical Permission

A Dutch-law compliant medical permission form for documenting patient consent to medical procedures and treatments in the Netherlands.

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What is a Medical Information Disclosure Consent Form?

What sections should be included in a Medical Information Disclosure Consent Form?

What sections are optional to include in a Medical Information Disclosure Consent Form?

What schedules should be included in a Medical Information Disclosure Consent Form?

Authors

Alex Denne

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