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Run: PHI Authorization to Release Form

PHI Authorization to Release Form template for collecting a patient’s consent to share protected health information with a named recipient, for a defined pur...

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Patient Information

Patient Full Name (required)

Date of Birth

Optional unless needed to distinguish records. Do not collect if not necessary.

Medical Record Number

Optional internal identifier if your organization uses one.

Phone Number

Recipient and Disclosure Details

Recipient Name (required)

Recipient Organization

Relationship to Patient

Information to Be Released (required)

Describe Other Information

Purpose and Duration

Purpose of Disclosure (required)

Authorization Start Date (required)

Authorization End Date

Leave blank if the authorization expires on a specific event instead of a date.

Expiration Event

Use this only if the authorization expires based on an event, such as completion of treatment or a specific claim decision.

Revocation and Consent

I understand that I may revoke this authorization in writing at any time, except to the extent action has already been taken in reliance on it. (required)

Yes No N/A

I understand that information disclosed under this authorization may no longer be protected by HIPAA if received by a non-covered entity. (required)

Yes No N/A

I authorize the release of the PHI described above to the recipient listed on this form. (required)

Yes No N/A

Patient Signature (required)

Signature Date (required)

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Email (required)

Your name (optional)

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