What this document does:

• Authorizes your health care providers to release your medical records and health information to the people you name.
• Covers the disclosures HIPAA privacy rules would otherwise block, so a spouse, adult child, or caregiver can get answers from a doctor’s office, hospital, or insurer without you present.
• Lets you name more than one authorized person and specify what kind of information they can access.

What’s inside:
A single-page authorization citing HIPAA’s Privacy Rule (45 CFR 164.508), space to name the individual whose records are covered, the person or people authorized to receive the information, the scope of what’s covered, and an expiration date or event if you want the authorization to end automatically. A signature line for you, plus a section covering a personal representative’s authority if you’re signing on someone else’s behalf.

Before you sign:
This form does not require witnesses. Some providers ask that it be notarized before they’ll accept it, even though HIPAA itself doesn’t require notarization, so check with the specific doctor’s office, hospital, or insurer you plan to use it with before you sign. A HIPAA authorization is different from a health care power of attorney or advance directive: it only controls who can see your medical information, not who can make medical decisions for you.

Orderly Affairs LLC provides self-help legal document templates. We are not a law firm, we are not your attorney, and using this kit does not create an attorney-client relationship. This is a general template; while a licensed attorney has reviewed it in general form, no attorney has reviewed it for your individual circumstances. You are responsible for signing this document, and notarizing it if the provider you’re using requires that, the way that provider requires.

Digital Download: Delivered as an instant PDF download after checkout, plus a confirmation email with your download link. This is a print-and-complete document: it does not have interactive fillable form fields, so you print it and fill in the blanks by hand, or open it in PDF or word-processing software to type over the blanks before printing. Available worldwide.

Printed & Shipped: Printed and shipped to you: a HIPAA Authorization Kit on standard paper in a flat mailer. Ships within the continental United States, plus carrier shipping calculated at checkout; international shipping for the printed kit is not currently available (the digital download is).