HIPAA Authorization Form

This HIPAA Authorization Form outlines the patient's consent for the use or disclosure of their protected health information (PHI). The form includes sections for the patient's information, the purpose of authorization, the entities authorized to release and receive PHI, a description of the PHI to be disclosed, the purpose of disclosure, and the expiration of the authorization. The form also details the patient's right to revoke the authorization and acknowledges that they understand the potential for redisclosure of their PHI. The patient or their personal representative must sign and date the form, and a witness signature may be required. The form concludes with contact information for the healthcare provider's Privacy Officer and an acknowledgment statement from the patient.

How It Works

This template has been set up as a Word document (.docx).

After purchase, you'll get access to the Word template immediately.

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FAQs

Google Docs version?

This template can easily be uploaded to use in Google Docs (via your Google Drive page).

Share with team

This purchase is for a single license for you to use with your team. If you want to share with additional teams, divisions or people from other companies, please get in touch (to discuss the extra licenses).

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Disclaimer: This template has been researched and compiled to be used as a starter template for your business. Ensure your final template meets relevant legal regulations before using it.