The Medical Records Release Form is a critical document used in Belgian healthcare settings when patient medical information needs to be shared with authorized parties. This form becomes necessary when patients require their medical records to be transferred to other healthcare providers, insurance companies, legal representatives, or other authorized recipients. It ensures compliance with the Belgian Patient Rights Act of 2002, the Belgian Privacy Act of 2018, and the EU General Data Protection Regulation (GDPR). The document includes specific provisions for patient consent, detailed identification of the information to be released, and clear purpose specification for the data transfer. It serves as both a legal authorization and a tracking mechanism for medical record transfers, protecting the rights and privacy of patients while facilitating necessary information sharing in the healthcare system.
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1. Patient Information: Full identification details of the patient including name, date of birth, address, contact information, and patient ID number if applicable
2. Healthcare Provider Information: Details of the healthcare provider/facility releasing the records, including name, address, and contact information
3. Recipient Information: Complete details of the person or entity who will receive the medical records
4. Records to be Released: Specific description of which medical records are to be released, including date ranges and types of documentation
5. Purpose of Disclosure: Clear statement of the purpose for which the medical records are being released
6. Duration of Authorization: Specification of how long the authorization is valid
7. Privacy Notice: GDPR-compliant privacy notice explaining how the information will be processed and protected
8. Patient Rights: Statement of patient rights regarding the release of medical records, including right to revoke authorization
9. Signatures: Space for patient signature (or legal representative) and date, with witness signature if required
1. Legal Representative Authorization: Additional section when the request is made by someone other than the patient, including proof of authority
2. Sensitive Information Authorization: Specific authorization for release of sensitive information (mental health, HIV status, genetic information) requiring explicit consent
3. Electronic Transfer Authorization: Additional provisions when records will be transferred electronically, including specific security measures
4. Cross-Border Transfer Notice: Required when medical records will be transferred outside of Belgium/EU, including additional GDPR requirements
5. Fee Information: If applicable, information about any fees associated with the release of records
1. Schedule A - Detailed Record List: Itemized list of specific medical records to be released, allowing for detailed selection
2. Schedule B - Privacy Policy: Detailed privacy policy and data protection information as required by GDPR
3. Schedule C - Authorization Proof: Attached documentation proving authority to act on patient's behalf (when applicable)
4. Schedule D - Fee Schedule: If applicable, detailed breakdown of any fees associated with the release of records
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