Consent to Disclose Medical Information Form

Consent to Disclose Medical Information Form Date: 1 November 2024 Patient Information: Patient Name: [Sarah Elizabeth Johnson] Date of Birth: [15/03/1988] Address: [42 Elmwood Avenue, London, SW1A 0AA] Phone Number: [07700 900345] I, Sarah Elizabeth Johnson, hereby authorise: Provider/Facility Name: [St. Jude's Medical Centre] Address: [123 High Street, London, W1G 9PN] Phone Number: [020 7946 0000] to release medical information to: Recipient Name: [Dr. Eleanor Vance] Organisation/Affiliation: [Hampstead General Practice] Address: [789 Oak Lane, London, NW3 1PA] Phone Number: [020 7946 1111] Relationship to Patient: [General Practitioner] Information to be Disclosed: * [All medical records from 2020 to present] * [Diagnosis: Type 2 Diabetes Mellitus] * [Treatment Plans: Insulin therapy, dietary recommendations] * [Medications: Metformin, Insulin Glargine] * [Lab Results: Recent HbA1c levels, fasting glucose] * [Imaging Reports: Annual retinal scans] * [Progress Notes: All consultation notes related to diabetes management] * [Other (specify): Summary of specialist consultations with endocrinology] Purpose of Disclosure: * [Continuity of care with general practitioner] * [Referral to a specialist] * [Insurance purposes] * [Legal purposes] * [Personal request] * [Other (specify): To facilitate comprehensive diabetes management and coordination between specialist and GP care.] This authorisation is valid for: * [One year from the date signed] * [Until (date): 1 November 2025] * [Until the purpose of disclosure has been achieved] * [Other (specify): Indefinitely, unless revoked in writing by the patient] I understand that I have the right to revoke this authorisation at any time by providing written notice to the provider/facility named above. I also understand that once information is disclosed, it may no longer be protected by privacy regulations. Patient Signature: [Sarah Elizabeth Johnson] Date: 1 November 2024 Witness Signature (if required): [Not required] Date: 1 November 2024