CONSENT TO RELEASE MEDICAL INFORMATION (RELEASE OF MEDICAL REPORTS

  AUTHORIZATION AND CONSENT FOR DISCLOSURE OF CRIMINAL
APPENDIX H SURROGATE CONSENT PROCESS ADDENDUM THE
BUILDING PLATFORM CHECKLIST (VERSION NOV2019) RESOURCE CONSENT NO

CONSENTIMIENTO INFORMADO PARA LA UTILIZACIÓN DE MUESTRAS BIOLÓGICAS
ELECTROCONVULSIVE THERAPY (ECT) YOUR RIGHTS ABOUT CONSENT
INFORMED CONSENT FORM AND HIPAA AUTHORIZATION STUDY

CONSENT TO DISCLOSE MEDICAL INFORMATION


CONSENT TO RELEASE MEDICAL INFORMATION

(Release of medical reports under the Access to Medical Reports Act 1998)


1. The Royal Air Force Recruiting and Selection Department of Occupational Medicine may need to seek further medical information from your medical practitioner.

2. If you give your consent for this you have the right to see the report before it is sent to this department.


3. You will have 21 days from requesting the report in which to ask your doctor to let you see the report.


4. Your doctor will explain to you if you cannot see any part of the report.


5. If you are given access to the report your doctor will not send it to this department until you give your consent.


6. You can ask for any incorrect or misleading information to be amended but if your doctor does not agree he is required to attach a statement to the report giving your views.


7. You have the right to see the report for up to 6 months after it was sent by your medical practitioner.


8. If your doctor provides you with a copy of the report he may charge you a reasonable fee.


9. You have the right to withhold consent for this department to request a medical report.E+W+S


FOR COMPLETION BY CANDIDATE (IN BLOCK CAPITALS)


SURNAME:

FORENAME:

OTHER INITIALS:

ADDRESS:

DATE OF BIRTH:

TELEPHONE NUMBER:


May the President of the Medical Board approach your doctor for a medical report?



YES



NO




NO I do NOT wish to have access



YES I DO wish to have access



I hereby give my consent for the release of medical information by my medical practitioner to the Department of Occupational Medicine; implicit in this consent is any subsequent communication with my medical practitioner to expand or clarify issues that may arise from the original report. I understand this requirement is solely to determine my medical suitability for military service and that consent is given for a period of 12 months from the date this form is signed.


Name and Address of your doctor












SIGNATURE:


DATE:





PATIENT ID NUMBER PATIENT NAME INFORMED CONSENT
TERMO DE CONSENTIMENTO DE USO DE BANCO DE
(REV 10919) INFORMED CONSENT FORM (ICF) TEMPLATE INFORMED CONSENT


Tags: medical information, my medical, medical, information, consent, (release, release, reports