HIPAA privacy authorization form (HIPAA release)

This HIPAA privacy authorization form lets a patient give written permission for a healthcare provider to use or share protected health information with a named person or organization. It covers the time period the release applies to, the specific records included, such as mental health, communicable disease or substance abuse treatment, and the purpose of the disclosure. It also states the patient's right to revoke the authorization in writing at any time.

Fill out the HIPAA privacy authorization form right here online, open it in a free desktop app to edit it, or download it as a PDF - just use the buttons below.