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1. Patient Information: Full legal name, date of birth, address, contact details, and health insurance information of the patient
2. Healthcare Provider Details: Information about the primary healthcare provider/facility authorized to share the information
3. Authorized Recipients: List of healthcare providers, institutions, or individuals authorized to receive the medical information
4. Scope of Authorization: Specific medical information authorized for sharing, including time period covered
5. Purpose of Disclosure: Clearly stated purpose(s) for which the medical information may be shared
6. Duration of Authorization: Validity period of the authorization and expiration date
7. Patient Rights: Statement of patient's rights including right to revoke authorization and receive copies
8. Signatures: Spaces for patient signature (or legal representative) and date, with witness signature if required
1. Legal Representative Authorization: Required when the form is signed by someone other than the patient (e.g., parent, guardian, power of attorney)
2. Specific Exclusions: Section listing any specific medical information that should NOT be shared
3. Emergency Contact: Optional section for emergency contact information
4. Electronic Records Consent: Additional consent specifically for electronic sharing of records, required if electronic sharing is anticipated
5. Language Confirmation: Required for non-native speakers, confirming the form has been explained in a language they understand
1. List of Authorized Information: Detailed checklist of specific medical information types authorized for sharing (e.g., test results, medications, diagnoses)
2. Recipient Details: Detailed information about each authorized recipient, including contact details and professional credentials
3. Privacy Notice: Summary of relevant privacy laws and patient rights under Swiss law
4. Revocation Form: Template form for revoking the authorization if needed
Healthcare
Insurance
Medical Research
Pharmaceuticals
Elder Care
Mental Health
Rehabilitation Services
Public Health
Healthcare Technology
Medical Education
Legal
Compliance
Medical Records
Patient Administration
Data Protection
Clinical Operations
Quality Assurance
Risk Management
Patient Services
Information Technology
Medical Director
Hospital Administrator
Privacy Officer
Data Protection Officer
Healthcare Compliance Manager
Medical Records Manager
Clinical Director
General Practitioner
Medical Secretary
Legal Counsel
Healthcare Risk Manager
Patient Relations Coordinator
Insurance Coordinator
Research Coordinator
Medical Office Manager
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ұԾ’s Security Promise
Genie is the safest place to draft. Here’s how we prioritise your privacy and security.
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We do not train on your data; ұԾ’s AI improves independently
All data stored on Genie is private to your organisation
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Your documents are protected by ultra-secure 256-bit encryption
We are ISO27001 certified, so your data is secure
Organizational security:
You retain IP ownership of your documents and their information
You have full control over your data and who gets to see it