Fillable Printable HIPAA Authorization Sample Form

HIPAA Authorization Sample Form

HIPAA Release of information

AUTHORIZATION FORM

I, ____________________________________hereby authorize _______________________ and

its affiliates, its employees and agents (collectively ________________________), to release to

_______________________________ [Insert full name of person/organization] my personal

health information maintained by ___________________ (e.g., information relating to the

diagnosis, treatment, claims payment, and health care services provided or to be provided to me

and which identifies my name, address, social security number, Member ID number) except the

following information about me:

__________________________________ [DESCRIBE INFORMATION NOT TO BE

DISCLOSED, IF ANY] for the purpose of helping me to resolve claims and health benefit

coverage issues. I understand that any personal health information or other information released

to the person or organization identified above may be subject to re-disclosure by such

person/organization and may no longer be protected by applicable federal and state privacy laws.

This authorization is valid from the date of my/my representative’s signature below and shall

expire the earlier of __________________________ [INSERT DATE/EVENT UPON WHICH

THIS AUTHORIZATION EXPIRES] or the date my coverage ends with _________________.

I understand that I have a right to revoke this authorization by providing written notice to

_______________________. However, this authorization may not be revoked if

_______________________, it’s employees or agents have taken action on this authorization

prior to receiving my written notice. I also understand that I have a right to have a copy of this

authorization.

I further understand that this authorization is voluntary and that I may refuse to sign this

authorization. My refusal to sign will not affect my eligibility for benefits or enrollment or

payment for or coverage of services.

Name of Member: __________________________________________

Signature of Member: _______________________________________

Date:______________________________

If applicable, Legal Representatives sign below:

By signing this form, I represent that I am the legal representative of the Member identified

above and will provide written proof (e.g., Power of Attorney, living will, guardianship papers,

etc.) that I am legally authorized to act on the Member’s behalf with respect to this

authorization form.

Name of Legal Representative: ____________________________________

Signature of Legal Representative: _________________________________

Date: _________________________________

Name of Witness: ________________________________________

Signature of Witness: _____________________________________