HIPAA authorization form
An authorization to release medical records: patient, who releases and who receives them, what records, purpose, expiration and the right to revoke.
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A general template, not legal advice
This is a general template, not legal advice. It includes the federal HIPAA elements, but many states add rules for HIV, mental health, substance use and minors' records, and many hospitals accept only their own form. Ask the records office whether they will take this one.
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Authorization to Release Health Information
HIPAA authorization, 45 CFR 164.508
I authorize the use and disclosure of my health information as described below.
| Patient name | Jordan Lee | Date of birth | March 14, 1988 |
|---|---|---|---|
| Patient address and phone | 123 Main St, Apt 4, Austin, TX 78701 (555) 010-0000 | ||
| Who may disclose (provider or plan) | Lakeview Family Medicine 2200 Lake Austin Blvd, Austin, TX 78703, fax (555) 010-0001 | ||
| Who may receive | Dr. Sam Park, Northwind Orthopedics 4410 Oak Hill Dr, Austin, TX 78745, fax (555) 010-0002 | ||
| Information to release | □ Complete medical record ■ Office visit and progress notes ■ Lab and test results ■ Imaging reports ■ Medication list □ Immunization records □ Discharge summary □ Billing records | ||
| Dates or other detail | January 1, 2024 to present | ||
| Purpose | Continuing care with a new specialist | ||
| This authorization expires | October 31, 2027 | ||
| Sensitive records: release only if checked and initialed | Initials |
|---|---|
| □ HIV or AIDS testing and treatment | |
| □ Sexually transmitted infections | |
| □ Mental health records (not psychotherapy notes) | |
| □ Substance use disorder treatment | |
| □ Genetic testing | |
| □ Reproductive health |
Please read
- 1. I may revoke this authorization at any time by sending a written notice to Lakeview Family Medicine. Revoking it does not undo any use or disclosure already made in reliance on it, and if I signed it to get insurance coverage, the insurer may still use the law's right to contest a claim under the policy.
- 2. Lakeview Family Medicine will not condition my treatment, payment, enrollment in a health plan or eligibility for benefits on whether I sign this authorization. I may refuse to sign it.
- 3. Information disclosed under this authorization may be redisclosed by the recipient, and once it is, it may no longer be protected by federal privacy law.
- 4. This authorization does not cover psychotherapy notes. Psychotherapy notes can be released only with a separate authorization for them alone.
- 5. Records from a federally assisted substance use disorder program may also need a consent that meets 42 CFR Part 2, and state law may require more for HIV, mental health or other sensitive records.
- 6. I have the right to receive a copy of this authorization.
Patient signature: ______________________ Date: ____________
Printed name: Jordan Lee
I agree that a photocopy or electronic copy of this signed form is as valid as the original. Keep a copy for your records.
How to use it
Enter the patient, the provider or plan that holds the records, and the person or office that should receive them. Check the kinds of records to release and add a date range if you want only part of the file. Sensitive records such as HIV, mental health or substance use treatment are released only if you check them here and initial them on paper. Add a purpose, or leave it empty for a request you are making for yourself, and pick an expiration date or event.
Print it, sign and date it, and send it to the records office by fax, mail or their patient portal. Keep a copy.
Things to watch
Psychotherapy notes are not included and need a separate form. If you only want your own records, you may not need an authorization at all: HIPAA gives you the right to ask for copies directly, and many providers have a records request form for that.
A parent, guardian or someone with a health care power of attorney can sign as personal representative. Write what gives them that authority and bring the paperwork that proves it.
Calculators that go with this
Frequently asked questions
Is a HIPAA authorization the same as a records request?
Not quite. A records request is you asking for your own records, which HIPAA lets you do without an authorization. An authorization is your permission for a provider to send your information to someone else, such as a new doctor, a lawyer, an insurer or a family member.
What does a valid HIPAA authorization need?
Under 45 CFR 164.508 it must describe the information, name who may disclose and who may receive it, state the purpose, give an expiration date or event, and carry your signature and date. It must also tell you that you can revoke it in writing, whether care can be conditioned on signing, and that the recipient may redisclose the information. This form includes all of these.
Can I cancel it later?
Yes. Send a written revocation to the provider named as the discloser. It stops future disclosures but does not pull back records already sent.
Is what I type saved anywhere?
No. Everything stays in your browser and nothing is sent to our server. If you refresh the page it is gone, so print, save a PDF or download the DOCX when you are done.