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HIPAA Authorization Form Template

Ensure Compliance with HIPAA Using This Simple Authorization Form

Obtaining patient consent for medical information can be a complex process. This HIPAA authorization form template is designed to help healthcare providers and patients seamlessly navigate consent requirements, ensuring privacy while facilitating necessary information exchange. You can easily adapt it for electronic signatures, speed up the approval process, improve the clarity of communication, and ensure compliance with HIPAA regulations, all while maintaining a professional appearance. Explore the live template to get started.

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Patient full name
Date of birth
Phone number
Email address
Medical record number (if known)
Preferred method to contact you about this authorization
Phone
Email
Either
Do not contact
Organization or provider authorized to disclose PHI
Person or organization authorized to receive PHI
Recipient email
Recipient phone
Recipient fax
Recipient mailing address (if mail or pickup)
Preferred delivery method for PHI
Secure portal
Encrypted email
Fax
Mail
In-person pickup
Records date range start
Records date range end
Select the information to be disclosed
If Other, describe the information to be disclosed
Include psychotherapy notes
Yes
No
If Other, describe the purpose of disclosure
Purpose of disclosure
Authorization expiration selection
On the expiration date specified below
One year from the signature date
Until revoked in writing
Upon the occurrence of the event described below
Expiration date
Expiration event (if selected)
I understand I may revoke this authorization in writing at any time
Yes
No
I understand that signing this authorization is voluntary and my treatment, payment, enrollment, or eligibility for benefits is not conditioned on it
Yes
No
I understand information disclosed may be subject to redisclosure by the recipient and may no longer be protected by HIPAA
Yes
No
I understand I am entitled to receive a copy of this authorization
Yes
No
Are you the patient or a personal representative
I am the patient
I am a personal representative
If a personal representative, relationship to patient
Parent
Legal guardian
Healthcare power of attorney or agent
Spouse or partner
Adult child
Not applicable
Other
Please Specify:
If a personal representative, describe your legal authority
Printed name of signer
Signature (type your full legal name)
Date signed
Would you like a copy of this authorization
Yes
No
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Paper art illustration related to HIPAA Authorization Form Template by FormCreatorAI

When to use this form

Use this authorization when you need to share a patient's protected health information with someone outside your practice. Common cases include sending records to a new specialist, letting a spouse or caregiver speak with your staff, providing documents for an insurance review, or giving an attorney billing details. It speeds referrals, reduces back-and-forth, and sets clear limits on what you may release and for how long. For general consent to treatment within your clinic, use our Medical authorization form. For insurance approvals, pair this with a Medicare prior authorization form when Medicare is involved. This form helps you comply with privacy rules while patients get faster care coordination and smoother billing.

Must Ask HIPAA Authorization Questions

  1. What is the patient's full legal name and date of birth?

    These identifiers match the authorization to the correct chart and prevent mix-ups with similar names. They reduce delays and stop disclosures tied to the wrong record.

  2. Are you the patient or a personal representative? If a representative, what is your legal relationship?

    This confirms who may sign and makes the authorization valid under privacy rules. If the patient is a minor, you can also collect treatment consent with a Child medical consent form.

  3. Who may receive the information, and how can we contact them?

    Listing the recipient's name, organization, address, phone, fax, and email ensures records reach the right person the first time. Clear recipient details cut repeat requests and reduce the risk of misdirected PHI.

  4. What specific records and dates of service are you authorizing us to disclose?

    Limiting scope (for example: visit notes, labs, imaging, billing) supports the minimum necessary standard and protects privacy. Including date ranges speeds fulfillment and avoids over- or under-sharing.

  5. What is the purpose of the disclosure and when should this authorization expire?

    Stating purpose (care coordination, insurance, legal, personal) helps your team process requests correctly and log the disclosure. An expiration date or event keeps consent time-bound, and you can note your right to revoke in writing at any time.

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