Hipaa Privacy Authorization Form printable pdf download

Hipaa Privacy Authorization Form

Instructions for Completing

HIPAA Privacy Authorization Form

If you would like some person other than yourself to have access to your medical records and information, and

allow health care providers to release such information to that person, you must authorize the release of the

information in writing. Since a Durable Power of Attorney for Health Care is only effective after you have lost

your capacity to make or communicate decisions, the Power of Attorney does not authorize release of medical

information to the person named while you remain competent. If you want some person other than yourself to

have access to that information now, while you remain competent, you need to complete and sign a HIPAA

Privacy Authorization Form, regardless of whether or not you also have a Durable Power of Attorney for Health

Care in place.

In Section 1 you need to insert the name of the health care provider (hospital, physician, etc.) who is authorized

to release the information, and the name of the person who is authorized to receive the information.

In Section 2 you first need to indicate what time period is covered by the authorization, and then what type of

information is allowed to be released.

In Section 4 you need to indicate how long the authorization is to remain effective, for example until a certain

date or until your death. You retain the power to revoke the authorization at any earlier time.

The form needs to be signed by the patient or by the personal representative of the patient, such as a parent if

the patient is a minor. You must complete a separate form for each health care provider you want to authorize

to release information. We suggest you photocopy the form for multiple use.

Hipaa Privacy Authorization Form