Request for third party to access a medical record

Section

I hereby consent to the disclosure of my private medical information to:

First Name: *

Last Name: *

Date of Birth: *

Please use this date format: DD/MM/YYYY

Relationship to you: *

Telephone Number: *

Email Address: *

Address:

Please select the statement(s) applicable:

Full and open-ended disclosure of any matter related to my medical record

Full disclosure of any matter related to my medical record for the period

From: *

Please use this date format: DD/MM/YYYY

To: *

Please use this date format: DD/MM/YYYY

Limited disclosure of the following aspects of my medical record:

Please state: *

I am aware that this consent may be revoked by me at any time. If my stance changes and I no longer consent for the above-named person to access my record, I will inform Horizon Healthcare immediately.

Signature: *

Date:

Please upload any relevant documents (we need to view valid photo ID/birth certificate of both the patient and their representative):

Maximum upload size: 67.11MB

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Request for third party to access a medical record

Section