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HIPAA Compliant

HIPAA Authorization Form

Authorize the release of your Protected Health Information to a named individual or organization. Complete all sections — leaving any section blank invalidates this form.

HIPAA Authorization Form

Authorization for the Release of Protected Health Information

Please complete all sections. If any sections are left blank, this form will be invalid. Use N/A if not applicable.

Section 1 — Patient / Plan Member Information

First Name *

Middle Name

Last Name *

Reference N°

Date of Birth

Address

City / State / ZIP

Section 2 — Individual / Organization Authorized to Disclose PHI

Name

Address

City / State / ZIP

Section 3 — Individual / Organization Authorized to Receive PHI

Name

Relationship to Patient / Plan Member

Telephone N°

Address

City / State / ZIP

Section 4 — Authorization Expiration Event or Date

Unless otherwise revoked by the patient/plan member, this authorization will expire on the event or date specified below. Enter N/A in both fields if the release is ongoing.

Expiration Event

Expiration Date

Section 5 — Health Information to be Disclosed — General

I authorize the following Protected Health Information to be disclosed:

Medical RecordsDental RecordsOther Non-Specific

Section 6 — Health Information to be Disclosed — Specific

I authorize the following Protected Health Information to be disclosed. Each checked item requires initials and a date.

Communicable Disease

Reproductive Health

HIV Test Results

Mental Health Records *

Substance Use Disorder

Other (please specify)

Psychotherapy Notes

* Requires a separate HIPAA Authorization Form — cannot be combined with other requests.

Section 7 — Purpose of the Release or Use of Health Information

Note: The sale of PHI authorized by this HIPAA Authorization Form will result in remuneration to the party specified in Section 2.

Section 8 — Authorization Information

I understand the following:

1. I authorize the use or disclosure of Protected Health Information as described above for the purpose indicated until such event or time as specified in Section 4.

2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party specified in Section 2. The revocation will prevent further disclosure of my health information by the party specified in Section 2 from the date of receipt. I understand a delay may exist if the party specified in Section 2 is not the covered entity authorized to disclose Protected Health Information. I also understand that a written revocation is not effective with respect to actions the covered entity or party specified in Section 2 took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage.

3. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this HIPAA Authorization Form.

4. If the party specified in Section 3 is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the disclosed health information may no longer be protected by federal and state privacy regulations.

5. I have a right to receive a copy of this HIPAA Authorization Form.

6 (if applicable). My substance abuse disorder records are protected under the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records and cannot be redisclosed without my written authorization.

Section 9 — Additional Conditions that Apply to this HIPAA Authorization Form

Section 10 — Signature by or on Behalf of Patient / Plan Member

Name of Patient / Plan Member (Print) *

Signature (type full name) *

Date *

Optional — Complete if signing on behalf of patient/plan member:

Name of signatory (if not patient / plan member)

Authority to sign on behalf of patient / plan member

Name of translator (if applicable)

Signature of translator (if applicable)

Developer Note: This form's submission handler must be routed through a HIPAA-compliant endpoint in production. localStorage is for development/prototype purposes only.