[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-287277-105":53,"doc-detail-287277-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","authorization-to-use-or-disclose-protected-health-information-phi","Authorization To Use or Disclose Protected Health Information (PHI)","","HIPAA-compliant authorization form used to permit a provider to use and disclose protected health information (PHI). The form collects patient identifiers and specifies which records to release, including diagnostic tests, doctor’s notes, lab, pathology, and radiology results, with optional inclusions for alcohol/drug treatment, mental health, and HIV-related information. It defines who will disclose and who will receive the information, the reason for disclosure, and how long the authorization remains valid. It also explains voluntary signing, revocation procedures, limits on redisclosure, and possible additional compliance requirements for sensitive categories.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-to-use-or-disclose-protected-health-information-phi/287277/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-to-use-or-disclose-protected-health-information-phi/287277.png","ImageObject",442,249,{"name":88,"@type":89},"Arica Lee","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-24","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":73},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information can be authorized for release using this form?","Question",{"text":108,"@type":109},"The authorization can cover the entire medical record or selected items such as diagnostic tests, doctor’s notes, lab results, pathology reports/specimens, and radiology reports/images. It also allows optional inclusion of alcohol/drug treatment, mental health, and HIV-related information.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is the expiration of the authorization determined?",{"text":113,"@type":109},"Expiration can be set by a specific time frame, when the record is received, or another stated explanation. The form explains that the expiration event can be tied to milestones such as the conclusion of a court case or a time period like “3 years from this date.”",{"name":115,"@type":106,"acceptedAnswer":116},"Can the patient revoke the authorization after signing?",{"text":117,"@type":109},"Yes. The form states that the patient may revoke the authorization at any time by completing a “Request to Revoke an Authorization” form, except to the extent action has already been taken based on the signed authorization.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},287277,1790210751,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":79,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},8796096645457,"https://ap-avatar.wpscdn.com/avatar/800003749518d68ffe3?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345340919836971","Authorization To Use or Disclose Protected Health Information (PHI)  \nPatient Name:   MRN\\#:    \nStreet:   DOB:    \nCity:   Phone:    \nST:   Zip:   NYP\\#:    \n(if available)  \nI authorize the release of the following health information (check below): Entire medical record  \nDiagnostic Tests Date(s):    \nDoctor's Notes (from Dr.  ) Date(s):    \nLab Results Date(s):    \nPathology Reports  Specimens   Date(s):    \nRadiology Reports  Images    \nInclude Alcohol/Drug Treatment information (initial here) Include Mental Health information (initial here)    \n_____  \nDate(s):  \n_________________________________________  \nInclude HIV-Related information (initial here)    \nAll of the above with the exception of:   Other:   \nWho will release/disclose information: Provider:    \nAddress:    \nCity, State, Zip:    \nWho will receive information: Name:    \nAddress:   City, State, Zip:   Email:    \nPhone:   Fax:   \nReason for Disclosure:   This authorization expires: ( ) specific time frame  , ( ) when record is received, ( ) other (explain)  \nI understand that:  \n􀁸 By signing this form, I am authorizing the use/disclosure of protected health information as indicated above.  \n􀁸 I am signing this form voluntarily. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.  \n􀁸 I may revoke this authorization at any time by completing a “Request to Revoke an Authorization” form, which is available at Weill Cornell Medicine’s Privacy Office. I understand that I may revoke this authorization except to the extent that action has been taken based on this authorization.  \n􀁸 If the receiving party is not subject to medical records privacy laws, the information may be re-disclosed by the recipient and may no longer be protected by federal/state law. Weill Cornell Medicine shall not be held liable for any consequences resulting from redisclosure.  \n􀁸 If the information to be released contains any information about HIV/AIDS, alcohol or substance abuse, mental health, or psychiatry notes, state or federal regulations may have additional compliance requirements.  \n􀁸 I may request a copy of this signed form.  \n􀁸 Weill Cornell Medical College may charge an administrative fee to cover the cost of labor, copying, or postage. The doctor’s office will inform me of any charges and arrange for payment.  \nPatient/Representative Signature  \nDate  \nIf the patient listed above is a minor or is unable to sign and you are a parent, legal guardian, or personal representative signing on behalf of this patient, please sign above and complete the following:  \nPrint name Relationship to patient  \nRev: 10/26/17 Page 1 of 1 Eff: 4/14/03  \nInstructions for the Use of the HIPAA-compliant Authorization Form to Release Health Information Needed for Litigation  \nThis form is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act (“HIPAA”) and its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful.  \nThe goal was to produce a standard HIPAA-compliant official form to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This form may be filled out on line and downloaded to be signed by hand, or downloaded and filled out entirely on paper.  \nWhen filing out Item 11, which requests the date or event when the authorization will expire,","cbCaiuosduKB1MKR","https://ap.wps.com/l/cbCaiuosduKB1MKR","pdf",241391,"English","# Authorization To Use or Disclose Protected Health Information (PHI)\n## Patient details and information to release\n## Recipient, disclosure provider, purpose, and expiration\n## Understanding the authorization and revocation","[{\"question\":\"What information can be authorized for release using this form?\",\"answer\":\"The authorization can cover the entire medical record or selected items such as diagnostic tests, doctor’s notes, lab results, pathology reports/specimens, and radiology reports/images. It also allows optional inclusion of alcohol/drug treatment, mental health, and HIV-related information.\"},{\"question\":\"How is the expiration of the authorization determined?\",\"answer\":\"Expiration can be set by a specific time frame, when the record is received, or another stated explanation. The form explains that the expiration event can be tied to milestones such as the conclusion of a court case or a time period like “3 years from this date.”\"},{\"question\":\"Can the patient revoke the authorization after signing?\",\"answer\":\"Yes. The form states that the patient may revoke the authorization at any time by completing a “Request to Revoke an Authorization” form, except to the extent action has already been taken based on the signed authorization.\"}]","Authorization To Use or Disclose Protected Health Information (PHI) | PDF",1789632103]