HIPAA Authorization Form, Authorization for the Release of Protected Health Information Instructions
This form contains 59 fields organized into 14 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Assessment/Evaluations Disclosure | ||
| Assessment/Evaluations Initial | Text |
Provide the initials for the Assessment/Evaluations disclosure.
|
| Assessment/Evaluations Date | Date |
Provide the date for the Assessment/Evaluations disclosure.
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| Assessment/Evaluations | Checkbox |
Check this box if you authorize the disclosure of your assessment and evaluation records.
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| Attendance/Appointment Records Disclosure | ||
| Attendance/Appointment Records Disclosure | Checkbox |
Check this box to authorize the disclosure of attendance and appointment records.
|
| Attendance/Appointment Records Initial | Text |
Enter your initials to acknowledge authorization for disclosure of attendance and appointment records.
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| Attendance/Appointment Records Date | Date |
Enter the date of authorization for disclosure of attendance and appointment records.
|
| Authorization Expiration Event or Date | ||
| text_18liiw | Text | |
| text_19nfwc | Text | |
| Discharge Summary Disclosure | ||
| Discharge Summary Initial | Text |
Provide the initial of the person authorizing the disclosure of the discharge summary.
|
| Discharge Summary | Checkbox |
Check this box if you authorize the disclosure of your Discharge Summary.
|
| Discharge Summary Date | Date |
Provide the date of the authorization for the disclosure of the discharge summary.
|
| General | ||
| text_57rzmg | Text | |
| text_58xjip | Text | |
| text_59mfbf | Text | |
| text_50gyae | Text | |
| text_52ivgh | Text | |
| text_53fywm | Text | |
| text_54hgnu | Text | |
| text_55awsc | Text | |
| signature_51avjg | Signature | |
| signature_56brkd | Signature | |
| General Health Information Disclosure | ||
| Mental Health Records | Checkbox |
Check this box if you authorize the disclosure of mental health records as part of general health information.
|
| Other Non-Specific | Checkbox |
Check this box if you authorize the disclosure of other non-specific general health information not explicitly listed.
|
| Other Non-Specific Details | Text |
Provide specific details if authorizing the disclosure of other non-specific health information.
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| Individual/Organization Authorized by Signatory to Disclose PHI | ||
| Disclosing Individual Name | Text |
Enter the full name of the individual authorized by the signatory to disclose Protected Health Information.
|
| Disclosing Organization Name | Text |
Enter the name of the organization authorized by the signatory to disclose Protected Health Information.
|
| Disclosing Contact Info | Text |
Provide the telephone number or email address for the individual or organization authorized to disclose Protected Health Information.
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| Disclosing Street Address | Text |
Enter the street address of the individual or organization authorized by the signatory to disclose Protected Health Information.
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| Disclosing City, State, ZIP | Text |
Enter the city, state, and ZIP code for the individual or organization authorized by the signatory to disclose Protected Health Information.
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| Individual/Organization Authorized by Signatory to Receive PHI | ||
| Receiver Name | Text |
Enter the name of the individual or organization authorized to receive Protected Health Information.
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| Receiver Relationship to Patient/Plan Member | Text |
Enter the relationship of the authorized individual or organization to the patient or plan member.
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| Receiver Telephone or Email | Text |
Enter the telephone number or email address of the individual or organization authorized to receive Protected Health Information.
|
| Receiver Address | Text |
Enter the street address of the individual or organization authorized to receive Protected Health Information.
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| Receiver City/State/ZIP | Text |
Enter the city, state, and ZIP code of the individual or organization authorized to receive Protected Health Information.
|
| Mental Health Diagnoses Disclosure | ||
| Mental Health Diagnoses | Checkbox |
Check this box if you authorize the disclosure of your mental health diagnoses.
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| Mental Health Diagnoses Initial | Text |
Provide your initials to authorize the disclosure of mental health diagnoses.
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| Mental Health Diagnoses Disclosure Date | Date |
Enter the date of disclosure for mental health diagnoses.
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| Other Specific Disclosure | ||
| Other Specific Disclosure Initial | Text |
Enter the initials of the person authorizing the disclosure for the 'Other' specified health information.
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| Other Specific Disclosure Date | Date |
Enter the date of authorization for the 'Other' specified health information.
|
| Other | Checkbox |
Check this box if you authorize the disclosure of other specific health information not previously listed and will provide details in the space provided.
|
| Other Specific Disclosure Details | Text |
Provide specific details about the 'Other' protected health information to be disclosed.
|
| Patient/Plan Member Information | ||
| Last Name | Text |
Please enter the last name of the patient or plan member.
|
| First Name | Text |
Please enter the first name of the patient or plan member.
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| Middle Name | Text |
Please enter the middle name of the patient or plan member.
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| Date of Birth | Date |
Please enter the date of birth for the patient or plan member.
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| Address | Text |
Please enter the street address of the patient or plan member.
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| City, State, ZIP Code | Text |
Please enter the city, state, and ZIP code of the patient or plan member.
|
| Purpose of Release | ||
| 1. Continuity of Care | Checkbox |
Check this box if the protected health information is being released for the purpose of continuity of care.
|
| 2. Coordination of Treatment | Checkbox |
Check this box if the protected health information is being released for the purpose of coordination of treatment.
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| 3. Legal | Checkbox |
Check this box if the protected health information is being released for legal purposes.
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| 4. Personal Use | Checkbox |
Check this box if the protected health information is being released for personal use.
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| Other Purpose of Release | Text |
Please provide a detailed explanation for the purpose of release when none of the predefined options apply.
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| 5. Other | Checkbox |
Check this box if the protected health information is being released for a purpose not listed, and then specify the purpose in the accompanying field.
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| Treatment Plan/Summary Disclosure | ||
| Treatment Plan/Summary | Checkbox |
Check this box if you authorize the disclosure of your Treatment Plan/Summary.
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| Treatment Plan/Summary Initial | Text |
Please provide the initials of the person authorizing the disclosure of the treatment plan or summary.
|
| Treatment Plan/Summary Date | Date |
Please provide the date of the authorization for the disclosure of the treatment plan or summary.
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| Verbal Consultation Disclosure | ||
| Verbal Consultation with Provider for continuity of care | Checkbox |
Check this box if you authorize the disclosure of information regarding verbal consultations with a provider for continuity of care.
|
| Verbal Consultation Initial | Text |
Provide your initials to authorize the disclosure of verbal consultation records for continuity of care.
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| Verbal Consultation Date | Date |
Enter the date of authorization for the disclosure of verbal consultation records for continuity of care.
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