Patient full name: Johnathan Smith
Date of birth: 15 March 1980
Medical record number or ID: 123456789
Authorized releasing party – name: Dr. Emily Johnson
Authorized releasing party – address/contact: 123 Health St, Springfield, SP1 2AB, Phone: 01234 567890
Recipient – name: Sarah Smith
Recipient – relationship to patient: Spouse
Recipient – address/contact: 456 Elm St, Springfield, SP3 4CD, Phone: 09876 543210
Description of information to be disclosed: The patient has authorized the release of all medical records pertaining to mental health treatment, excluding any records related to drug and alcohol treatment. No HIV/AIDS information is to be disclosed.
Format of disclosure: Electronically via secure portal
Purpose of disclosure: The disclosure is for care coordination purposes as requested by the patient.
Expiration of authorization: This authorization will expire on 1 November 2025.
Revocation and rights statement: The patient has the right to revoke this authorization in writing at any time, except to the extent that action has already been taken based on this authorization.
Redisclosure limitations and legal protections: The information disclosed may not be redisclosed without the patient's consent, in accordance with state and federal laws protecting patient privacy.
Signature of patient: Johnathan Smith
Date of signature: 1 November 2024
Printed name of patient: Johnathan Smith
Interpreter name (if applicable): Maria Gonzalez
Interpreter signature (if applicable): Maria Gonzalez
Patient full name: [insert patient full name] (insert full legal name of the individual whose information is being released; only include if explicitly mentioned in the consultation)
Date of birth: [insert patient date of birth] (write full date format; include only if stated)
Medical record number or ID: [insert patient medical record number] (enter only if this information is explicitly included)
Authorized releasing party – name: [insert name of person or organization authorized to release information] (enter full name of the clinician, health service, or practice authorised to disclose the records; only include if mentioned)
Authorized releasing party – address/contact: [insert address and contact information of releasing party] (write the full mailing address and contact details in one line; include only if provided)
Recipient – name: [insert name of recipient individual or organization] (enter full name of the party authorised to receive the records; include only if stated)
Recipient – relationship to patient: [insert relationship of recipient to the patient] (write relationship as described; only include if mentioned)
Recipient – address/contact: [insert address and contact information of recipient] (write the recipient's full mailing address and contact information in one line; include only if explicitly stated)
Description of information to be disclosed: [insert specific description of medical information to be disclosed] (write a short paragraph in full sentences detailing which types of records the patient has authorised for release, particularly noting sensitive categories such as mental health, drug and alcohol treatment, and HIV/AIDS information. Clearly indicate if any specific categories are to be excluded. Include only information specifically stated.)
Format of disclosure: [insert format in which the information should be shared] (state how the information is to be delivered, e.g. electronically, paper, portal; use a single line or short sentence and include only if specified)
Purpose of disclosure: [insert purpose of disclosure] (write a short paragraph in full sentences stating the reason for the disclosure. This may include care coordination, legal purposes, or personal request. Include only if the purpose is explicitly stated. If the patient indicates the disclosure is at their request, include that phrase only if used verbatim.)
Expiration of authorization: [insert duration or expiration of authorization] (state the date or event after which the authorization is no longer valid. Include only if an expiration is explicitly specified.)
Revocation and rights statement: [insert revocation statement and patient rights] (write a paragraph in full sentences explaining the patient's right to revoke the authorization in writing and the limitations if the information has already been released. Include only if this explanation is documented or standard wording is used.)
Redisclosure limitations and legal protections: [insert re-disclosure limitations and legal disclaimers, if mentioned] (include a paragraph explaining any restrictions on redisclosure and any relevant state or federal laws protecting the released information. Only include if these limitations are explicitly mentioned.)
Signature of patient: [insert signature of patient] (include signature only if documented)
Date of signature: [insert date of patient signature] (write the date in full format; include only if stated)
Printed name of patient: [insert printed name of patient] (include only if separately stated or signed)
Name of person signing on behalf of patient: [insert name of proxy signer] (include only if someone else signs for the patient)
Legal authority of proxy signer: [insert legal authority of person signing on behalf of patient] (briefly describe the nature of the legal authority, such as guardian, attorney, or healthcare proxy; include only if stated)
Interpreter name (if applicable): [insert name of interpreter or translator] (only include if a translator was involved and named)
Interpreter signature (if applicable): [insert signature of interpreter or translator] (include only if interpreter signed the document)
(Never come up with your own patient details, authorization purposes, categories of information, method of disclosure, expiration date, legal statements, or signer authority – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Maintain all formatting and paragraph structure exactly as described in the example note.)
