________
________

________

________
________

RE: Consent to Release or Transfer of Health Information

To Whom It May Concern,

I am writing to give ________ consent to release or transfer (hereinafter "transfer") my health information, as detailed below. My details are as follows:

Name: ________
Date of birth: ________
Address:
________

1. Information to be transferred:

I consent to the transfer of the following information:

________

2. Purpose of the transfer:

I am consenting to this transfer of information, for the following purpose:

________

3. Recipient of the information:

I consent to the information being transferred to the following person/organisation:

Name of organisation: ________
Address: ________
Phone: ________
Email: ________
Relationship to patient: ________

4. Method of transfer:

I request that you use the following method to transfer my information to the above organisation:

________

5. Duration of consent:

This consent is valid until you receive a written notice of revocation from me.

6. Right to revoke consent:

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7. Indemnity and release:

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8. Patient signature:

By signing below, I confirm that the above information is true and correct and that I am providing this consent voluntarily.

Patient signature: ..........................................................................

Print patient name:..........................................................................

Date of signing:..........................................................................

Witness signature: ..........................................................................

Print witness name: ..........................................................................

Witness phone: ..........................................................................

Witness email: ..........................................................................

OFFICE USE ONLY:

Received by:..........................................................................

Date of receipt:..........................................................................

Method of transfer of information:..........................................................................

Date of transfer:..........................................................................