Consent to Disclose Medical Information (SA472.2412)

## Consent to Disclose Medical Information (SA472.2412) **Patient Information** * **Patient Name:** John Smith * **Date of Birth:** 12/03/1978 * **Address:** 12 Acacia Avenue, Anytown, AB1 2CD * **Phone Number:** 07700 900123 **Purpose of Disclosure** * To share occupational therapy progress reports with the patient's GP, Dr. Eleanor Vance, to ensure coordinated care and inform medical management. **Information to be Disclosed** * Occupational therapy assessment reports. * Treatment plans. * Progress notes. * Discharge summary. **Recipient of Information** * **Name:** Dr. Eleanor Vance * **Title:** General Practitioner * **Address:** The Health Centre, 10 Downing Street, Anytown, AB1 2CD * **Phone Number:** 07700 900456 **Duration of Consent** * This consent is valid for one year from the date of signature, or until revoked by the patient. **Patient Acknowledgement** I, John Smith, understand that the information I am consenting to disclose may include details of my medical history, treatment, and progress in occupational therapy. I understand that I have the right to revoke this consent at any time by notifying my occupational therapist in writing. I understand that the information will be used for the purpose stated above and will be kept confidential by the recipient. * **Patient Signature:** * **Date:** 01 November 2024 **Witness Information** * **Witness Name:** Jane Doe * **Witness Signature:** * **Date:** 01 November 2024 **Occupational Therapist Information** * **Occupational Therapist Name:** Dr. Thomas Kelly * **Occupational Therapist Signature:** * **Date:** 01 November 2024