1. Special Categories of Information: Additional authorization for sensitive information such as HIV status, mental health records, or genetic testing - required only if such records are included

2. Guardian/Proxy Authorization: Section for guardian or proxy details and authority - required only when the patient is a minor or legally incapable of giving consent

3. Emergency Contact Information: Details of emergency contact person - optional but recommended for comprehensive record-keeping

4. Cost Declaration: Information about any fees associated with the release of records - required only if there are applicable charges

5. Digital Records Format: Specifications for digital record format and delivery - required only for electronic record transfers

1. Schedule A: Detailed Record List: Itemized list of specific medical records being requested, with dates and document types

2. Schedule B: Proof of Identity: Copies of required identity documentation for verification purposes

3. Schedule C: Supporting Documentation: Any additional documentation supporting the authority to request records (e.g., power of attorney, court orders)

4. Appendix 1: Patient Rights Information: Detailed explanation of patient rights regarding medical records under South African law

5. Appendix 2: Privacy Notice: POPIA-compliant privacy notice explaining how the released information will be processed and protected