HIPAA Privacy Authorization Form

Authorization form for patients to permit the use and disclosure of protected health information, including scope, recipient, purpose, and revocation terms.

Patient Information

• Patient Full Name
• Date of Birth
• Medical Record Number (if known)
• Phone Number

Authorized Disclosure Details

• Information to Be Used or Disclosed
• If Other, describe the information
• Person or Organization Receiving the Information
• Recipient Contact Information (optional)
• Purpose of Disclosure

Authorization Period

• Authorization Start Date
• Authorization Expires
• Expiration Date
• Expiration Event

Patient Rights and Acknowledgement

• I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken based on this authorization.
• I understand that information disclosed under this authorization may no longer be protected by HIPAA if the recipient is not a covered entity or business associate.
• I understand that signing this authorization is voluntary and that treatment, payment, enrollment, or eligibility for benefits will not be conditioned on signing unless permitted by law.
• Patient Signature
• Date Signed

Representative Information

• Is this authorization being signed by a personal representative?
• Representative Name
• Relationship to Patient
• Documentation of Authority