The Medical Records Consent Form Template UK is offered in multiple formats, including PDF, Word, and Google Docs, featuring customizable and printable examples.
Medical Records Consent Form Template UK Editable – PrintableSample
Medical Records Consent Form Template UK 1. Patient Information 2. Health Care Provider Information 3. Purpose of Consent 4. Information to be Shared 5. Duration of Consent 6. Patient Rights 7. Acknowledgment of Receipt 8. Signature and Agreement 9. Declaration and Signatures
PDF
WORD
Examples
[Patient’s Name]
[Patient’s ID Number]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Name of the Healthcare Provider]
[Provider’s ID Number]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
This consent form allows [Name of the Healthcare Provider] to access, use, and share my medical records for the purposes of treatment, healthcare operations, and billing.
I consent to the sharing of my medical records, including but not limited to: [Specify types of records, e.g., medical history, treatment records, lab results, and diagnostic images].
I understand that I have the right to request the amendment of my medical records, and I may revoke this consent at any time in writing.
This consent is valid until [Specify end date or condition], or until it is revoked in writing.
I understand that I can withdraw this consent at any time by providing written notice to [Healthcare Provider’s Name] at [Provider’s Address].
This consent form shall be governed by the laws of [Jurisdiction, e.g., England and Wales].
[Signature of the Patient]
[Name of the Patient]
[Signature of the Healthcare Provider]
[Name of the Healthcare Provider]
[Patient’s Name]
[Patient’s ID Number]
[Patient’s Address]
[Patient’s Phone]
[Patient’s Email]
[Name of the Healthcare Provider]
[Provider’s ID Number]
[Provider’s Address]
[Provider’s Phone]
[Provider’s Email]
This consent form grants [Name of the Healthcare Provider] the authority to collect, use, and disclose my medical records for treatment, payment, and healthcare operations.
I understand that the information shared may include, but is not limited to: [Detail specific records such as hospital admissions, treatment plans, and prescription records].
I acknowledge that I have the right to access my medical records and to request corrections to any inaccurate information in those records.
This consent will remain in effect until [Specify duration or condition], or sooner if revoked in writing by me.
I am aware that I can revoke this consent at any time by sending a written notice to [Healthcare Provider’s Name] at [Provider’s Address].
This form shall be governed by the laws applicable in [Jurisdiction, e.g., England and Wales].
[Signature of the Patient]
[Name of the Patient]
[Signature of the Healthcare Provider]
[Name of the Healthcare Provider]
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