PDF
Word
HIPAA Consent Form
What Is a HIPAA Consent Form?
A HIPAA Consent Form is a written authorization completed by the patient who lets their medical provider disclose health information to the individual or organization named in the document. The patient may present this consent form to their current healthcare provider and ask them to disclose protected health information.
Alternate Name:
- HIPAA Patient Consent Form.
Download a printable HIPAA Consent Form template through the link below.
This document will share your health records, results of physical examinations and laboratory tests, X-ray reports, and financial documentation related to your treatment with people you trust.
How to Write a HIPAA Consent Form?
Traditionally, a HIPAA Consent Form sample is provided by the medical facility to the patient at the latter's request. It can then be personalized - for example, the patient adds their name and the name of the individual who will get access to their medical history and treatment.
If you have to create a document from scratch, follow these steps to prepare a HIPAA Patient Consent Form:
- Write down your full name and identify the healthcare provider.
- Certify your consent to allow the healthcare provider to share the protected health information listed in the form with the person or organization that represents you. There are no limitations here - you can name your family member, friend, attorney, or religious mentor you can confide in. Add their contact information so that the hospital or clinic in question can reach out to them on your behalf.
- State the duration of the consent - the person can get access to your health information only within a specific period of time. Alternatively, you can provide an open-ended authorization.
- Outline the extent of the authorization. You may forbid the disclosure of certain facts as long as you specify them in the form - for instance, the patient is within their rights to exclude the consent to share mental health records, HIV and AIDS diagnosis and treatment details, or substance abuse treatment.
- Indicate the reasoning behind granting another person or organization the right to review your medical history and prognosis. You may name the physician you have known for a long time and who, in your opinion, will make the correct medical decision on your behalf if they learn about the treatment from your current medical provider.
- Confirm you know about your right to revoke the authorization at any time and you are making the decision to release your personal information voluntarily.
- Sign and date the consent form. To add an extra level of protection to your interests, you may prepare and sign the document before a notary public or witnesses.
Not what you were looking for? Check out these related forms:
Download HIPAA Consent Form
1
2
