Fillable Printable HIPAA Authorization Form

HIPAA Authorization Form

HIPAA Privacy Authorization Form

**Authorization for Use or Disclosure of Protected Health Information

(Required by the Health Insurance Portability and Accountability Act, 45 C.F.R.

Parts 160 and 164)**

**1.$Authorization**$

I$authorize$________________________________________$(healthcare$provider)$to$use$

and$disclose$the$protected$health$information$described$below$to$

______________________________________________$(individual$seeking$the$information).$

**2.$Effective$Period**$

This$authorization$for$release$of$information$covers$the$period$of$healthcare$

from:$

a. □ ______________ to ______________.

**OR**

b. □ all past, present, and future periods.

**3.$Extent$of$Authorization**$

a.$□$I$authorize$the$release$of$my$complete$health$record$(including$records$

relating$to$mental$healthcare,$communicable$diseases,$HIV$or$AIDS,$and$treatment$of$

alcohol$or$drug$abuse).$$

**OR**

b.$□$I$authorize$the$release$of$my$complete$health$record$with$the$exception$

of$the$following$information:$$

$□$Mental$health$records$$$

$□$Communicable$diseases$(including$HIV$and$AIDS)$$$

$□$Alcohol/drug$abuse$treatment$$

$□$Other$(please$specify):$_______________________________________________$$

4.$This$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.$$

5.$This$authorization$shall$be$in$force$and$effect$until$___________________$(date$

or$event),$at$which$time$this$authorization$expires.$

6.$I$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.$$

7.$I$understand$that$my$treatment,$payment,$enrollment,$or$eligibility$for$

benefits$will$not$be$conditioned$on$whether$I$sign$this$authorization.$$

8.$I$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$law.$

Signature of patient or personal representative

Printed name of patient or personal representative and his or her relationship to patient

Date