The Medical Release Form is a crucial document in the Dutch healthcare system that facilitates the authorized sharing of patient medical information while ensuring compliance with privacy laws and patient rights. This document is essential when medical information needs to be shared between healthcare providers, with insurance companies, or with other authorized parties. It must comply with the Medical Treatment Agreement Act (WGBO), the Dutch implementation of GDPR (AVG), and other relevant healthcare privacy regulations. The form includes specific provisions for different types of medical information, duration of authorization, and clear identification of all parties involved in the information exchange. It is particularly important in cases of patient transfers, insurance claims, continued care scenarios, or when medical records are needed for legal or personal purposes.
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1. Patient Information: Complete identification details of the patient including name, date of birth, address, and patient ID number
2. Healthcare Provider Information: Details of the healthcare provider or medical facility releasing the information
3. Information to be Released: Specific description of medical information authorized for release, including time period covered
4. Purpose of Release: Clear statement of the reason(s) for releasing medical information
5. Recipient Information: Complete details of the person or organization authorized to receive the medical information
6. Duration of Authorization: Specific time period for which the release authorization is valid
7. Rights and Notices: Statement of patient rights under Dutch law, including right to revoke authorization
8. Privacy Statement: Declaration of how information will be protected in accordance with AVG/GDPR requirements
9. Signature Block: Space for patient (or legal representative) signature, date, and witness if required
1. Mental Health Records Authorization: Additional section when release includes mental health records, requiring specific consent under Dutch law
2. Legal Representative Authorization: Required when someone other than the patient is authorizing the release
3. Minor Patient Provisions: Special provisions when the patient is under 16 years old
4. Emergency Contact Information: Optional section for including emergency contact details
5. Electronic Transfer Consent: Specific authorization for digital transfer of medical records
6. Language Preference: For patients requiring documentation in languages other than Dutch
7. Research Use Authorization: Additional section when data may be used for research purposes
1. Types of Medical Information Checklist: Detailed checklist of specific medical information types that can be released
2. Fee Schedule: If applicable, breakdown of any costs associated with records release
3. Approved Recipients List: If multiple recipients are authorized, complete list with contact details
4. Revocation Form: Template form for revoking the medical release authorization
5. Patient Rights Summary: Detailed explanation of patient rights under Dutch healthcare laws
Relevant legal definitions
Medical Information
Protected Health Information
Healthcare Provider
Medical Records
Authorization Period
Personal Data
Sensitive Personal Data
Legal Representative
Authorized Recipient
Treatment
Medical History
Disclosure
Consent
Revocation
Data Controller
Data Processor
Electronic Health Record
Healthcare Institution
Patient Rights
Professional Confidentiality
Processing
Transfer of Data
Third Party
Minor Patient
Emergency Contact
Protected Health Information
Healthcare Provider
Medical Records
Authorization Period
Personal Data
Sensitive Personal Data
Legal Representative
Authorized Recipient
Treatment
Medical History
Disclosure
Consent
Revocation
Data Controller
Data Processor
Electronic Health Record
Healthcare Institution
Patient Rights
Professional Confidentiality
Processing
Transfer of Data
Third Party
Minor Patient
Emergency Contact
Clauses
Consent
Authorization
Data Protection
Privacy
Information Access
Confidentiality
Duration
Revocation Rights
Information Transfer
Data Processing
Patient Rights
Healthcare Provider Obligations
Record Maintenance
Liability
Emergency Provisions
Electronic Records
Third Party Access
Legal Representative Authority
Minor Patient Provisions
Governing Law
Dispute Resolution
Authorization
Data Protection
Privacy
Information Access
Confidentiality
Duration
Revocation Rights
Information Transfer
Data Processing
Patient Rights
Healthcare Provider Obligations
Record Maintenance
Liability
Emergency Provisions
Electronic Records
Third Party Access
Legal Representative Authority
Minor Patient Provisions
Governing Law
Dispute Resolution
Relevant Industries
Healthcare
Medical Services
Insurance
Elder Care
Mental Healthcare
Rehabilitation Services
Pharmaceutical
Research Institutions
Healthcare Technology
Legal Services
Relevant Teams
Medical Records
Compliance
Legal
Patient Services
Privacy and Data Protection
Quality Assurance
Healthcare Operations
Administrative Services
Risk Management
Information Technology
Relevant Roles
Medical Director
Healthcare Administrator
Privacy Officer
Compliance Manager
Medical Records Coordinator
Healthcare Provider
General Practitioner
Medical Specialist
Nurse Practitioner
Legal Counsel
Insurance Claims Processor
Patient Services Representative
Data Protection Officer
Quality Assurance Manager
Healthcare Operations Manager
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