HIPAA Authorization Form

HIPAA Authorization Form

Authorization for Use and Disclosure of Protected Health Information (PHI)

This authorization permits the use and disclosure of Protected Health Information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and applicable federal and state privacy laws.

Completion of this form allows the organization to use or disclose health and related information as necessary to provide services, coordinate care, conduct operations, or fulfill administrative functions.

1. Individual Information
Full Name:
Date of Birth:
/
/
Phone Number:
Email Address:
Address:
City / State / ZIP:
2. Authorization
I,
(Individual Name), authorize
(Organization Name)

to use and disclose my Protected Health Information for the following purposes (check all that apply):

  • Treatment / Service Delivery
  • Care Coordination / Case Management
  • Billing and Payment Processing
  • Insurance Verification / Claims Processing
  • Healthcare Operations (Quality Assurance, Compliance, Audits)
  • Legal / Regulatory Compliance
  • Program Eligibility Determination
  • Other:
3. Information to Be Disclosed

The following information may be used or disclosed (check all that apply):

  • Entire Record
  • Medical / Clinical Records
  • Behavioral Health / Mental Health Records (if applicable)
  • Substance Use Treatment Records (if applicable and permitted by law)
  • Medication Records
  • Treatment / Service Plans
  • Assessments, Evaluations, and Progress Notes
  • Billing and Insurance Information
  • Demographic Information
  • Other:
4. Authorized Recipients
Recipient 1
Name:
Relationship:
Organization:
Phone:
Email:
Recipient 2
Name:
Relationship:
Organization:
Phone:
Email:
5. Expiration of Authorization

This authorization will expire on:

/
/

If no date is specified, this authorization will expire one (1) year from the date of signature, unless otherwise required by applicable law.

6. Revocation of Authorization

I understand that I may revoke this authorization at any time by submitting a written request to:

(Organization Name)

Revocation will not apply to information already disclosed in reliance on this authorization prior to receipt of the revocation request.

7. Individual Rights
Voluntary Authorization
I understand that signing this form is voluntary. Refusal to sign will not affect my eligibility for services, treatment, or benefits.
Right to Access
I understand that I have the right to inspect or obtain a copy of my Protected Health Information as permitted by law.
Right to Copy
I understand that I am entitled to receive a copy of this signed authorization.
Redisclosure Notice
I understand that once information is disclosed to an authorized recipient, it may no longer be protected under HIPAA and may be subject to redisclosure by the recipient.
8. Signature

By signing below, I authorize the use and disclosure of my Protected Health Information as described in this form.

Printed Name:
Signature:
Date:
/
/
9. If Signed by Authorized Representative
Representative Name:
Relationship:
Legal Authority:

(Examples: Legal Guardian, Power of Attorney, Healthcare Proxy)

10. Organization Contact Information
Organization Name:
Address:
City / State / ZIP:
Phone:
Email:
Internal Use Only
Date Received:
/
/
Processed By:
Notes: