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1. Patient Information: Full legal name, date of birth, address, and insurance information of the patient
2. Healthcare Provider Details: Name, address, and professional credentials of the healthcare provider/facility releasing the information
3. Recipient Information: Name and contact details of the person or institution authorized to receive the medical information
4. Scope of Release: Specific description of medical information to be released (e.g., complete records, specific date ranges, particular conditions)
5. Purpose of Disclosure: Clear statement of the reason for releasing the medical information
6. Authorization Statement: Explicit authorization language confirming the patient's consent to release the specified information
7. Data Protection Notice: Statement regarding GDPR and German data protection law compliance
8. Signature Block: Space for patient signature, date, and witness signature if required
1. Time Limitation: Section specifying an expiration date for the authorization, used when the release should not be indefinite
2. Special Conditions: Any specific conditions or restrictions on the use of the released information
3. Legal Representative Authorization: Required when the patient is a minor or legally incapable of providing consent
4. Revocation Rights: Details about the right to revoke the authorization and the process for doing so
5. Electronic Transfer Consent: Specific authorization for electronic transmission of records, if applicable
6. Translation Certificate: Required when the letter needs to be used in non-German speaking jurisdictions
1. List of Specific Records: Detailed inventory of specific medical records being released
2. Proof of Identity: Copies of identification documents of the patient or legal representative
3. Legal Representative Documentation: Copies of power of attorney or legal guardianship documents, if applicable
4. Specific Consent Forms: Additional consent forms required for sensitive information (e.g., psychiatric records, HIV status)
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Quality Assurance
Clinical Operations
Insurance Processing
Medical Administration
Research and Development
Medical Doctor
Healthcare Administrator
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Healthcare Facility Manager
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Medical Research Coordinator
Patient Care Coordinator
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