Free Template

HIPAA Authorization Form

1 signer
1 Personnel
Use this template

Hipaa Authorization Form

A HIPAA authorization form gives covered entities permission to use protected health information for purposes other than healthcare operations, payment or treatment. We’re offering you a template which will help you create your form easily.
hipaa authorization form template

How to Get Medical Records for Someone Else?

There’re 3 options. You can collect it from an administrator of a healthcare provider. If that’s not possible, you can collect the records from an adult patient or the patient’s legal guardian. And if you can’t manage to get the records, you can contact a healthcare  representative

Who needs to complete a HIPAA authorization form?

Many healthcare professionals need to complete HIPAA request forms on a regular basis. The requirement of  have people sign HIPAA privacy consent documents arises before they begin treatment. Whenever a medical professional accepts a new patient, it’s good practice to have them sign a HIPAA release to minimize the risk of legal liability in the future. Adult patients may complete the forms themselves. If the patient is a cilild and has a legal caretaker or a power of attorney, that caretaker will need to sign the form for them.
a description hipaa authorization form

A Description

A description of what private health information is covered by the form and how it will be shared.

identification hipaa authorization form


The identities of the people or groups who will be able to share the information.

legal language hipaa authorization form

Legal Language

Necessary legal language for different state release forms and types of treatment.

exception hipaa authorization form


An explanation of the individual’s right to revoke their authorization and any exceptions to that right.

FAQ About Our HIPAA Authorization Form Template

A medical consent form and a HIPAA privacy authorization form are completely different. Medical consent forms cover specific procedures and medical actions a patient will undergo. On the other side, a HIPAA privacy form covers the sharing of medical and health information. For example, a medical consent form might cover a patient’s consent to removing their wisdom teeth at a particular dental surgical center. Without a signed HIPAA consent document, that surgical center would not be able to share information about the patient’s surgery with other healthcare providers. The HIPAA form permits sharing the information, not the medical procedure itself.

 The HIPAA Privacy Rule expressly requires an authorization for uses or disclosures of protected health information for all kinds of marketing communications. There’re 2 circumstances – first, when the communication occurs in a face-to-face encounter between the covered entity and the individual and second, he communication involves a promotional gift of nominal value.

" Undoubtedly one of the best eSignature application available in the market right now. Would love to recommend Fill. "

Liam Washington

Ready to get started
with this template?

Click the button below to add this template to your account. If you do not have an account, you can sign up for a free trial to start using this template.