HIPAA Authorization Form

Authorization for the Release of Protected Health Information

Please complete all sections of this form. If any sections are not applicable, enter "N/A".

Important Information

This form allows you to authorize the release of your protected health information. All fields are required unless marked optional. You can sign electronically using your mouse/touchpad or by typing your name.

Section 1 - Patient/Plan Member Information

Section 2 - Individual/Organization Authorized to Disclose PHI

Who is authorized to release your protected health information?

Section 3 - Individual/Organization Authorized to Receive PHI

Who should receive your protected health information?

Section 4 - Authorization Expiration Event or Date

When should this authorization expire? Enter N/A in both fields if the release is ongoing.

Section 5 - Health Information to be Disclosed (General)

Select the types of health information to be disclosed:

Section 6 - Health Information to be Disclosed (Specific)

Select any specific health information types to be disclosed and provide the date:

* Requests for psychotherapy notes require a separate HIPAA Authorization Form and may not be combined with any other request.
** Note: If requesting psychotherapy notes, no other items should be checked.

Section 7 - Purpose of the Release or Use of Health Information

Select the purpose(s) for releasing this information:

Note: The sale of PHI authorized by this form will result in remuneration to the party specified in Section 2.

Section 8 - Authorization Information

I understand the following:

1. I authorize the use or disclosure of Protected Health Information as described above for the purpose indicated until such event or time as specified in Section 4.

2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party specified in Section 2. The revocation will prevent further disclosure of my health information by the party specified in Section 2 from the date of receipt. I understand a delay may exist if the party specified in Section 2 is not the covered entity authorized to disclose Protected Health Information to the party specified in Section 2. I also understand that a written revocation is not effective with respect to actions the covered entity or party specified in Section 2 took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage.

3. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this HIPAA Authorization Form.

4. If the party specified in Section 3 is not a HIPAA Covered Entity or Business Associate as defined in 45 CFR §160.103, the disclosed health information may no longer be protected by federal and state privacy regulations.

5. I have a right to receive a copy of this HIPAA Authorization Form.

6 (if applicable). My substance abuse disorder records are protected under the federal regulations governing the Confidentiality of Substance Use Disorder Patient Records and cannot be redisclosed without my written authorization.

Section 9 - Additional Conditions

Section 10 - Signature

If signing on behalf of the patient/plan member:

By submitting this form, you acknowledge that all information provided is accurate and complete. This form will be securely stored and reviewed by authorized personnel.