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1. Patient Information: Complete identification and contact details of the patient
2. Healthcare Provider Information: Details of the medical facility and healthcare providers involved
3. Nature of Medical Information Release: Specific description of what medical information is being authorized for release
4. Purpose of Release: Clear statement of why the medical information is being released and how it will be used
5. Duration of Authorization: Timeframe for which the release authorization remains valid
6. Rights and Revocation: Patient's rights regarding the release and how to revoke authorization
7. Privacy Notice: POPIA-compliant statement about information protection and privacy measures
8. Signature and Declaration: Formal authorization signatures, dates, and declaration of understanding
1. Emergency Contact Authorization: Additional section for authorizing emergency contacts to access medical information
2. Special Medical Conditions: Section for noting specific medical conditions requiring special attention or handling
3. Minor Patient Provisions: Additional requirements when the patient is under 18 years old
4. Mental Health Records: Specific provisions for release of mental health information under Mental Health Care Act
5. Third Party Authorization: Section for authorizing specific third parties (like insurers or other healthcare providers) to access information
6. International Transfer Consent: Additional provisions for when medical information may be transferred internationally
7. Research Use Authorization: Optional consent for use of medical information in research studies
1. Schedule A - Types of Medical Information: Detailed list of specific medical information categories being released
2. Schedule B - Authorized Recipients: List of specific individuals or entities authorized to receive the medical information
3. Schedule C - Privacy Policy Summary: Summary of the healthcare provider's privacy policy and data protection measures
4. Appendix 1 - Glossary of Medical Terms: Definitions of medical and technical terms used in the release form
5. Appendix 2 - Patient Rights Summary: Summary of patient rights under South African law regarding medical information
Confidential Information
Healthcare Provider
Health Record
Medical Information
Personal Information
Protected Health Information
Patient
Legal Guardian
Medical Practitioner
Healthcare Facility
Treatment
Disclosure
Authorization Period
Revocation
Electronic Health Record
Consent
Data Subject
Information Officer
Mental Health Records
Special Personal Information
Processing
Third Party
Emergency Contact
Medical Emergency
Responsible Party
Healthcare Services
Release Authorization
POPIA
Health Care Act
Authorization
Confidentiality
Information Access
Privacy Protection
Data Processing
Duration
Revocation Rights
Emergency Provisions
Third Party Access
Information Security
Patient Rights
Healthcare Provider Obligations
Liability
Record Maintenance
Information Transfer
Data Protection
Disclosure Limitations
Termination
Governing Law
Healthcare
Medical Insurance
Pharmaceuticals
Medical Research
Healthcare Technology
Elder Care
Mental Healthcare
Rehabilitation Services
Public Health
Occupational Health
Legal
Compliance
Medical Records
Patient Services
Administration
Risk Management
Data Protection
Clinical Operations
Quality Assurance
Privacy
Medical Doctor
Healthcare Administrator
Compliance Officer
Medical Records Manager
Privacy Officer
Legal Counsel
Nurse Practitioner
Clinical Director
Hospital Administrator
Medical Secretary
Data Protection Officer
Risk Manager
Patient Services Coordinator
Healthcare Facility Manager
Medical Information Officer
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