The Consent To Release Medical Information Form Template – Australia is offered in multiple formats, including PDF, Word, and Google Docs. Each version is designed to be both editable and printable, ensuring you can easily adapt them to your requirements.
Consent To Release Medical Information Form Template – Australia Editable | PrintableSample
1. Patient Information 2. Releasing Party Information 3. Receiving Party Information 4. Purpose of Disclosure 5. Information to be Released 6. Expiration of Consent 7. Right to Revoke 8. Acknowledgment of Understanding 9. Signature of Patient or Authorized Representative
PDF
WORD
Examples
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Recipient’s Name]
[Recipient’s Title/Position]
[Recipient’s Organization]
[Recipient’s Address]
[Recipient’s Phone]
[Recipient’s Email]
I, [Patient’s Name], hereby authorize the release of my medical information for the following purpose: [Specify the purpose, e.g., treatment, legal reasons, insurance claims].
I consent to the release of the following medical records:
– [Specific medical records, e.g., treatment history, diagnostic tests, prescriptions]
– [Other related information, if applicable].
This consent is valid until [Specify expiration date or event, e.g., completion of treatment, a specific date]. If no expiration date is provided, this consent will remain in effect until revoked by me in writing.
I understand that I have the right to revoke this consent at any time by providing written notice to [Provider’s Name/Organization].
By signing below, I acknowledge that I have read and understood the terms of this consent form and grant permission for the release of my medical information as described above.
[Patient’s Signature]
[Patient’s Name]
[Patient’s Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
I, [Patient’s Name], authorize [Name of the Healthcare Provider or Organization] to disclose my medical information to [Recipient’s Name], for the purpose of [State the purpose, e.g., continuing care, legal matters, insurance processing].
I consent to the release of the following types of information:
– [Specific documents, e.g., lab results, treatment notes, medication lists]
– [Other pertinent information, if any].
This consent remains valid until [Specify duration, e.g., one year from the date of signature, until the completion of the specified purpose]. If I do not provide an expiry date, this consent is effective indefinitely unless revoked.
I am aware that I can withdraw my consent at any time by submitting a written request to [Provider’s Name or Organization].
I understand the nature of this authorization and the potential risks of disclosing my medical information, including the possibility of re-disclosure by the recipient.
By signing below, I confirm that I am giving my consent freely and voluntarily.
[Patient’s Signature]
[Patient’s Name]
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