HIPAA Authorization Form

Learn about HIPAA Authorization Forms and download a free sample to use when requesting access to protected health information.

By Ericka Pingol on Apr 08, 2024.

Fact Checked by Ericka Pingol.

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What is a HIPAA Authorization Form?

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that sets national standards for protecting sensitive patient health information. HIPAA Privacy Rule safeguards the privacy of individually identifiable health information, while the HIPAA Security Rule establishes national security standards for protecting health data. The rules protect medical records, protected health information (PHI), and other personally identifiable information held by healthcare providers, health plans, and clearinghouses.

HIPAA also requires that covered entities have physical, technical, and administrative safeguards to protect protected health information from unauthorized access or disclosure. All HIPAA-covered entities must have comprehensive policies and procedures to ensure compliance with the HIPAA Security Rule.

To further ensure compliance with HIPAA requirements, covered entities must create a. This form allows patients to authorize the release of their PHI to other individuals or organizations. The agreement should be written in clear language and include all details of who is authorized to access the patient’s PHI, the purpose for which it is being disclosed, how long the authorization will be effective, and a statement that the patient can revoke the authorization at any time.

Printable HIPAA Authorization Form

Download this HIPAA Authorization Form to ensure you maintain compliance.

How does it work?

You can use our free printable HIPAA Authorization Form template to ensure your patients properly authorize their PHI access. The authorization form includes sections for patient information, details of the entity receiving the medical information, purpose of disclosure, and description of the medical information to be released.

This pre-made template is fully digital and easy to use. Here's how to get started:

Step One: Download the PDF

Get a copy of the HIPAA Authorization Form template using the link on this page. Alternatively, you can get it from the Carepatron app or our resources library.

Step Two: Fill in the Information

Once you've downloaded it, open up the form and ask your patient to start filling in the applicable information, such as the patient's name, contact details, the reason for the authorization, and a description of the medical information that needs to be released.

Step Three: Obtain patient signature

Once all sections are complete, have the patient sign and date the form. The signature must be obtained to ensure it was given of the patient's own free will.

Step Four: Keep a copy in your file

Keep a copy of the completed authorization in your patient records. If the form is sent electronically, ensure you have an electronic copy to store in the patient's chart.

Step Five: Keep track of the expiration date

It is important to note that the authorization does expire, typically after one year. Keep track of the expiration date and obtain new authorization if the form expires.

HIPAA Authorization Form example (sample)

We have created a HIPAA Authorization Form PDF example to illustrate how our free template works. This sample shows how to fill up a HIPAA Authorization Form that can be used as a legally binding document. You may view the sample here or download it as PDF for reference.

Download the free HIPAA Authorization Form example (sample) 

HIPAA Authorization Form example (sample)

When would you use this Template?

This template is used to obtain permission from a patient, or their legal representative, to allow healthcare providers access to the person’s protected health information. You and your patient may also use our free HIPAA Authorization Form to:

Request information from a patient’s health plan or healthcare provider

By completing a HIPAA Authorization Form, patients can authorize healthcare providers or their health plan to release and receive protected health information.

Share protected health information with other organizations

If your patient wishes to share their protected health information with another organization, such as a research center or an insurance company, the HIPAA Authorization Form is the best way to do so. The form lets them safely and securely share information related to their health with those who need it.

Receive a copy of their protected health information

Patients can also use the HIPAA Authorization Form to request a copy of their protected health information. This is especially useful if they transfer to another healthcare provider, as they can easily bring the information. It also helps them keep records of their health history and any treatments they have had.

Acquire consent from patients prior to disclosing medical information

Using this HIPAA Authorization Form, you can obtain written consent from patients before divulging their health information. This serves as a protective measure for both you and the patient in case of any legal disputes regarding data breaches or unauthorized access, ensuring clarity on responsibility.

Show adherence to HIPAA regulations

The form acts as proof of compliance with HIPAA guidelines that mandate healthcare providers to maintain the security and confidentiality of all PHI. Keeping a signed HIPAA Authorization Form on record is crucial to ensure strict adherence to these regulations.

Who is this HIPAA Authorization Template for?

This free template is designed for use by healthcare providers, including:

  • Doctors
  • Nurses
  • Dentists
  • Mental health professionals
  • Physical therapists
  • Counselors
  • Other healthcare professionals

It can also be utilized by hospitals or other organizations handling PHI to ensure compliance with HIPAA regulations. Additionally, insurance companies, attorneys, and third-party entities may benefit from this form when requesting access to confidential medical information.

Electronic Health Records Software Feedback

Why use Carepatron as your HIPAA Authorization Form app?

Don't let paperwork steal precious moments from your patients! Empower your healthcare practice with Carepatron, the all-in-one practice management software designed to streamline your day, enhance patient outcomes, and take your practice to new heights.

Our intuitive and user-friendly solution organizes all patient data, simplifies documentation, accelerates billing processes, and more – all seamlessly integrated into one reliable system. Carepatron makes it easier to provide quality care in today's complex healthcare environment.

With Carepatron, you can:

  • Automatically update patient information in real-time
  • Create pre-built templates for documentation to save time
  • Easily generate helpful reports and analytics
  • Streamline the billing process with integrated payment processing
  • Track all lab results, medications, and clinical notes in one place
  • Enable secure patient communication with two-way messaging

Plus, our dedicated customer service team is available to answer any questions and ensure that your practice can take full advantage of all the features Carepatron has to offer.

For healthcare professionals ready to elevate their practice to the next level, Carepatron is the perfect solution. Join thousands of other successful practices and start streamlining your workflow today!

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Who uses HIPAA Authorization Forms?
Who uses HIPAA Authorization Forms?

Commonly asked questions

Who uses HIPAA Authorization Forms?

HIPAA Authorization Forms are used by healthcare organizations, medical practices, and other entities that must comply with the HIPAA regulations.

When do you use HIPAA Authorization Forms?

You can use a HIPAA Authorization Form whenever patient information needs to be disclosed for a non-treatment reason. Examples include clinical trials, third-party payment requests, and research studies.

How do you store completed HIPAA Authorization Forms?

Completed HIPAA Authorization Forms should be stored securely. The best practice is to store them in an encrypted, password-protected electronic format. It's important to track who can access the forms and ensure only authorized personnel have access.

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