HIPAA Authorization to Release Medical Records
Authorize a healthcare provider to use or disclose your protected health information to a person you choose.
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About HIPAA Authorization
A HIPAA Authorization is a written permission that allows a healthcare provider or health plan to use or disclose your protected health information for purposes you specify. It reflects the privacy protections under the federal Health Insurance Portability and Accountability Act.
The authorization identifies who may release the information, who may receive it, what information is covered, and the purpose of the disclosure. It also includes an expiration date or event and your right to revoke the permission in writing.
This document is often used to share records with family members, attorneys, insurers, or other providers. Because it releases sensitive information, it should describe the scope of the disclosure clearly and be signed and dated by the patient or an authorized personal representative.
Who needs to complete it
- Patients who want records shared with a family member or caregiver
- Individuals sending medical records to an attorney or insurer
- People transferring records to a new healthcare provider
- Personal representatives acting on behalf of a patient
- Anyone who needs to authorize a specific disclosure of health information
How to fill out HIPAA Authorization
- 1Enter the patient name and identifying details.
- 2Identify the provider or entity authorized to release the information.
- 3Identify the person or organization who may receive the information.
- 4Describe the specific information to be disclosed.
- 5State the purpose of the disclosure.
- 6Enter an expiration date or event for the authorization.
- 7Review the statements about your right to revoke the authorization.
- 8Sign and date the form, or have an authorized representative sign.
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Frequently asked questions
What does a HIPAA authorization do?
It gives a provider or health plan your written permission to use or disclose your protected health information for the purpose and to the people you specify.
Can I cancel a HIPAA authorization?
Yes. You can generally revoke an authorization in writing, though it does not undo disclosures already made in reliance on it.
Is this form the same everywhere?
This is a general template. HIPAA is a federal law, but specific requirements and additional protections can vary by state and by provider, so confirm the requirements that apply to you.
Who can sign the authorization?
The patient signs, or a personal representative authorized to act on the patient's behalf may sign.