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1. Date and Location: Current date and place of execution of the consent authorization
2. Authorizing Party Details: Full name, address, and other relevant identification details of the person giving consent
3. Recipient Party Details: Full name, address, and other relevant identification details of the person/organization receiving the authorization
4. Purpose of Authorization: Clear statement of the specific purpose(s) for which consent is being given
5. Scope of Authorization: Detailed description of what actions/access/rights are being authorized
6. Duration of Authorization: Time period for which the authorization remains valid
7. Declaration of Consent: Express statement of consent and confirmation that it is given freely and with full understanding
8. Signature Block: Space for signature, date, and witness details if required
1. Third Party Authorization: Section to include when consent extends to allowing third parties to act on behalf of the recipient
2. Revocation Terms: Details about how and when the consent can be withdrawn, if applicable
3. Special Conditions: Any specific conditions or limitations on the authorization
4. Privacy Statement: Required when the authorization involves handling of personal or sensitive information
5. Capacity Declaration: Statement confirming the authorizing party's legal capacity, required in cases involving medical consent or when capacity might be questioned
6. Witness Requirements: Section for witness details and signatures when required by law or requested by parties
1. Schedule A - Authorized Activities: Detailed list of specific activities or access rights being authorized
2. Schedule B - Identity Verification Documents: Copies or details of identification documents provided by the authorizing party
3. Schedule C - Related Forms: Any additional forms or documents that need to be completed as part of the authorization
4. Appendix 1 - Terms and Conditions: Detailed terms and conditions governing the authorization, if applicable
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Client Services
Medical Administration
Records Management
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Compliance Officer
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Human Resources Manager
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Research Coordinator
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