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 Aug 2, 2025.

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.

HIPAA Authorization Form Template

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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.

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.

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Benefits of free HIPAA Authorization Form

Our pre-made, fully digital template is a fantastic resource for busy healthcare professionals and their patients. Here are its advantages:

It simplifies information sharing with other parties

A HIPAA Authorization Form on file makes sharing PHI with other entities, such as insurance companies or attorneys, easy. This form lets you quickly demonstrate that you have obtained consent to release the information.

It's easy to use and fill out

Our template is designed for simplicity and ease of completion, making it accessible and user-friendly for healthcare providers and patients.

It eliminates paperwork

Using a digital version of the form eliminates the need for manual paperwork or lengthy data-sharing processes. This enables you to quickly and securely provide access to PHI without concerns about compliance with regulations.

It helps protect patient privacy rights

Our template helps protect patient privacy rights by ensuring that all PHI is treated and stored securely. It also ensures that information is only released with the patient's explicit authorization, as HIPAA regulations require.

Commonly asked questions

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

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.

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.