HIPAA Authorization Form

Many parents and caregivers don't realize that healthcare providers are not able to disclose health related information for anyone 18 years and older without a signed HIPPA consent. If you wait to complete this document, you could run into real barriers if the affected patient encounters an emergency situation and is unable to communicate their desires. This applies especailly to parents and their children off at college if something should happen and there is no HIPPA authorization.

A signed HIPAA authorization is like a permission slip that permits healthcare providers to disclose your health information to anyone you specify and it does not have to be notarized or witnessed. This document alone, signed in advance will allow anyone named in it to get information from the treating hospital. Young people who want parents to be involved in a medical emergency, but fear disclosure of sensitive information, can prevent that; This HIPAA authorization does not have to be all-encompassing and can be limited so as not to disclose information about sex, substance abuse, mental health, or other details they might want to keep private.

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1

Enter the name of the health care provider (hospital, physician, etc.) who would then be authorized to disclose your health information to anyone you specify below.

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2

Enter the name of the person who is authorized to receive the information.

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