Third Party Access 3rd Party Authorisation (Consent to share patient data with specified 3rd party) I consent to the disclosure of information held in my medical to the third party named on this authorisation form. Full Disclosure is: of any matter related to my medical records and treatment including but not limited to: – Appointments – make; amend; cancel or enquire. – Prescriptions – request; collect; discuss; past and present. – Test Results – collect; discuss; past and present. – Referrals, request; collect; discuss; past and present – Update contact information, address; contact numbers. – Discuss my medical condition / treatment / records past and present with practice staff. Please Select from the following 2 options belowFull Disclosure Having read the information above I Consent to give Full Disclosure Optional OR Limited Disclosure – Please tick all that apply Prescription queries Optional Test Results Optional Referral queries Optional Other Optional Please Specify Patients DetailsFull Name Optional Address Street Address Address Line 2 City Postcode Email Date of Birth Day Month Year Home Telephone OptionalMobile Telephone OptionalDeclaration I acknowledge I can revoke this authorisation at any time in the future by writing to the practice manager. Third Party DetailsFull Name Optional Address Street Address Address Line 2 City Postcode Email Relationship to Patient Home Telephone OptionalMobile Telephone Optional
