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HIPAA Authorization Form

Complete the Authorization for Use and Disclosure of Protected Health Information online, then print and sign. No Adobe Reader required.

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Authorization for Use and Disclosure of Protected Health Information (PHI)

Please complete all applicable fields, then print and sign.

Patient information
Information to be released to (requestor)
Facility authorized to release PHI
Expiration

If I fail to specify an expiration date or event, this authorization will expire twelve (12) months from the date on which it was signed.

Purpose of disclosure
Description of information to be used or disclosed
Record typeStarting dateEnding date
Record typeStarting dateEnding date
Specially protected information
The protected health information listed below WILL BE released when included in the above medical information unless specifically indicated otherwise.
I understand that
  1. I may refuse to sign this authorization and that it is strictly voluntary.
  2. If I do not sign this form, my health care and the payment for my health care will not be affected unless stated otherwise.
  3. I have the right to revoke this authorization at any time in writing and must present the written revocation to the provider authorized to release the protected health information. If I do revoke this authorization, it will not apply to information that has already been released to this authorization.
  4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be redisclosed.
  5. I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.
Signatures

I have read the above and authorize the disclosure of the protected health information as stated.

Produced by Southern Medical Document Solutions, L.L.C.