HIPAA Authorization Form

Patient/Client Authorization for Use and Disclosure of Protected Health Information (PHI)

Instructions: This form allows for the use and disclosure of your Protected Health Information (PHI) as required under the Health Insurance Portability and Accountability Act (HIPAA). Please complete this form to authorize or limit how your information is shared.

Client Information

• Full Name: ____________________________________________
• Date of Birth: ______ / ______ / _______
• Phone Number: ________________________________________
• Address: ______________________________________________

Authorization Details

I, [Client Name], authorize [Agency Name] to:

• Use and disclose my Protected Health Information (PHI) for the following purposes:
  • ☐ Medical Treatment
  • ☐ Case Management
  • ☐ Coordination of Care
  • ☐ Billing and Payments
  • ☐ Other: ___________________________________________

Information to be Disclosed

• ☐ Entire Medical Record
• ☐ Medication Records
• ☐ Treatment and Care Plans
• ☐ Billing Information
• ☐ Other: ___________________________________________

Authorized Recipients

Name of Individuals or Entities authorized to receive my PHI:

1. Name: ________________________________________
   • Relationship: ______________________________
   • Contact Info: ______________________________
2. Name: _______________________________________
   • Relationship: ______________________________
   • Contact Info: ______________________________

Expiration of Authorization

• This authorization will expire on: ____ / ____ / ____
  (If no date is provided, this authorization will expire one year from the signature date below.)

Revocation

I understand that I have the right to revoke this authorization at any time by providing written notice to [Agency Name]. I acknowledge that my revocation will not affect any actions taken before receipt of the revocation.

Client Rights

1. Right to Refuse Authorization: I understand that I am not required to sign this form and that my refusal to sign will not affect my ability to receive care.
2. Right to Information: I understand that I am entitled to a copy of this signed authorization and that I may inspect or obtain a copy of my health information as provided under HIPAA regulations.

Signature and Date

By signing below, I authorize the use and disclosure of my Protected Health Information as described above.

• Client/Authorized Representative Signature: _________________________________________
• Date: ____ / ____ / _______

If signed by an Authorized Representative:

• Print Name: ___________________________________________
• Relationship to Client: __________________________________

Contact for Questions and Concerns

If you have questions about this form or need further assistance, you may reach out to us for a more customized form based on your state-specific regulation.

Contact Waiver Consulting Group:

• Phone: 302.888.9172
• Email: licensing@waivergroup.com

Our team at Waiver Consulting Group specializes in Medicaid waiver compliance and can provide expert guidance tailored to your agency's needs.