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.
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HIPAA Privacy Authorization Form
Authorization for Use or Disclosure of Protected Health Information
(Required by the Health Insurance Portability and Accountability Act – 45 CFR Parts 160 and 164)
1. I hereby authorize to use and/or disclose the {{health_care_provider ? health_care_provider : '__________________________'}} to use and/or disclose the protected health information described below to {{individual_name ? individual_name : '__________________________'}}.
2. Authorization for Release of Information. Covering the period of health care from {{computedStartDate ? computedStartDate : '______________'}} to {{computedEndingDate ? computedEndingDate : '______________'}}. all past, present and future periods.
I hereby authorize the release of my complete health record (including records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).
I hereby authorize the release of my complete health record with the exception of the following information:
a. [___] I hereby authorize the release of my complete health record (including records relating to mental health care, communicable diseases, HIV or AIDS, and treatment of alcohol/drug abuse).
OR
b. [___] I hereby authorize the release of my complete health record with the exception of the following information:
3. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.
4. This authorization shall be in force and effect until {{expiration_event}} {{computedExpirationDate}} __________________________ , at which time this authorization expires.
5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.
6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.
7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
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Signature of Patient or Personal Representative
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Print Name of Patient or Personal Representative
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Relationship to Patient
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Date
