This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Consent Form For Release Of Information In Philadelphia
State:
Multi-State
County:
Philadelphia
Control #:
US-00460
Format:
Word;
Rich Text
Instant download
Description
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FAQ
Function The nature of the procedure or intervention. The risks and benefits of the procedure or intervention. Reasonable alternatives. The risks and benefits of alternatives. An assessment of the patient's understanding of these elements 1011
Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.
The informed consent process should ensure that all critical information about a study is completely disclosed, and that prospective subjects or their legally authorized representatives adequately understand the research so that they can make informed choices.
Consent must be informed Your consent is only valid if you're aware of the consequences of giving or not giving your consent at the time you make the decision. An organisation or agency should: clearly explain how they want to handle your personal information.
Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.