Hospital Medical Release Notes

- Patient full name: Johnathan Smith - Date of birth: 15 March 1980 - Medical record number or ID: 123456789 - Facility name: St. Mary's Hospital - Facility address and contact: 123 Health St, London, SW1A 1AA, 020 7946 0958 - Date of treatment: 1 October 2024 - 15 October 2024 - Recipient – name: Dr. Emily Johnson - Recipient – relationship to patient: Primary Care Physician - Recipient – address/contact: 456 Wellness Ave, London, SW1A 2BB, 020 7946 1234 - Purpose of disclosure: The patient has requested the release of medical records for continuity of care and further treatment planning with their primary care physician. - Types of records to be released: Admission notes, operative notes, discharge summaries. - Information to be excluded (if any): Mental health records. - Format of disclosure: Electronic via secure portal. - Disclosure expiration: 1 November 2025 - Patient rights and revocation clause: The patient has the right to revoke this authorisation at any time by submitting a written request to the medical records department. Revocation will not affect any disclosures made prior to the receipt of the revocation. - Signature of patient: Johnathan Smith - Date of signature: 1 November 2024 - Printed name of patient: Johnathan Smith