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It collects the individual’s details, the recipient’s contact and identity information, the specific categories of information to disclose, and the purpose of disclosure. The authorization includes an expiration of 24 months unless an earlier date is provided, plus voluntary signature requirements, witness signature requirements for Illinois residents, and instructions for personal representatives.",{"@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":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/hipaa-authorization-for-the-use-and-disclosure-of-health-information/288377/",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/hipaa-authorization-for-the-use-and-disclosure-of-health-information/288377.png","ImageObject",442,249,{"name":88,"@type":89},"Ophelia","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":76},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Who can use this HIPAA authorization form, and what does it allow?","Question",{"text":108,"@type":109},"The form is completed and signed by the individual or a personal representative to allow UnitedHealthcare to share the person’s protected health information with the listed recipient.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How do I choose what information will be shared?",{"text":113,"@type":109},"Select one option under Part C: either all information, all information except specific categories, or only the specific information you authorize.",{"name":115,"@type":106,"acceptedAnswer":116},"When does the authorization expire and what happens after signing?",{"text":117,"@type":109},"The authorization expires 24 months from the signature date unless an earlier date is provided or state rules require a shorter period. Signing is voluntary, and you may end the authorization at any time in writing without affecting sharing that already occurred.","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},288377,1790038675,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":76,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":76,"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},7971461741311,"https://ap-avatar.wpscdn.com/avatar/74000253aff267980c6?x-image-process=image/resize,m_fixed,w_180,h_180&k=1779345379180704826","HIPAA Authorization fortheUse and Disclosure of Health Information  \nBy completing and signing this form, I, or my personal representative, agree to allow UnitedHealthcare* to share my protected health information (PHI) to the person or company listed below.  \n\n| Part A: Individual’s information\u003Cbr>Last name: First name: MI:\u003Cbr>DOB (MM/DD/YYYY): Address:\u003Cbr>City: State: ZIP code:\u003Cbr>Phone number (with area code):\u003Cbr>Email address:\u003Cbr>ID number (See ID card):\u003Cbr>Group number (See ID card): |\n| --- |\n| Part B: Person who will get my information\u003Cbr>This person is authorized to get my information. I understand once disclosed, my information is shared, it may no longer be protected by federal privacy laws and might be further shared without my permission.\u003Cbr>Last name: First name: MI:\u003Cbr>DOB (MM/DD/YY)(Optional):\u003Cbr>Relationship to member/patient:\u003Cbr>Address:\u003Cbr>City: State: ZIP code:\u003Cbr>Phone number (with area code):\u003Cbr>Email address: |\n| Part C: Description of information to be shared\u003Cbr>I authorize the following information to be shared. Select one of the options below.\u003Cbr>All my information. This may include information about alcohol or substance use disorders, genetic information, HIV/AIDS, infectious diseases, mental or behavioral health and reproductive health; OR All my information EXCEPT the categories selected below. If I do not check a box, all information will be selected.\u003Cbr>Alcohol or substance use disorders HIV/AIDS Reproductive health\u003Cbr>Genetic information Mental or behavioral health Infectious diseases\u003Cbr>I authorize only the sharing of the following information: |\n\n\n| Part D: Purpose of disclosure\u003Cbr>My health information is being shared at my request or at the request of my personal representative; OR\u003Cbr>My health information is being shared for the following purpose: |\n| --- |\n| Part E: Expiration\u003Cbr>I understand this authorization will expire 24 months from the date of my signature unless I provide an earlier date below or am a resident of a state requiring a shorter time limit.\u003Cbr>Date sooner than 24 months (MM/DD/YYYY): |\n| Part F: Signature\u003Cbr>I understand and agree that signing this form:\u003Cbr>• Is voluntary.\u003Cbr>• Not signing this form will not impact my ability to get treatment, payment for health care services, or healthcare benefits I am entitled to.\u003Cbr>• I can end this authorization at any time by notifying UnitedHealthcare in writing. I understand that ending this authorization will not affect any sharing of my information that has already happened.\u003Cbr>Signature: Date (MM/DD/YYYY):\u003Cbr>Witness Signature (For Illinois Residents Only): Date (MM/DD/YYYY): |\n\nPersonal representatives  \nIf you are a parent, note that below. For all other types of legal authority, you must include documentation (for example, Power of Attorney, Guardianship, etc.) of your legal authority to act as a Personal Representative.  \nI agree that by signing this form, I have the legal authority to act for the Individual. If I am not the parent of a minor child, I am attaching legal documents to this request. I understand that not submitting any required documents will make this form incomplete. If you are making this request for a minor child, we may need more information before this request will be processed.  \nPlease complete the following:  \nLegal representative (print full name):  \nLegal relationship to individual:  \nAddress:  \nCity: State: ZIP code:  \nSignature: Date (MM/DD/YYYY):  \nKeep a copy of this form foryour records. Send the signed and completed form to:  \nUnitedHealthcare, Attn: Shared Access Ops, PO Box 6, Huntingdon Valley, PA 19006 or fax to: 1-877-875-0797.  \n*UnitedHealthcare and its subsidiaries, affiliates, employees, agents, and subcontractors, including Optum Behavioral Health, Optum Rx retail/pharmacy benefits, and Optum Health.  \n© 2025 United HealthCare Services, Inc. All rights reserved. All UnitedHealthcare trademarks and logos are owned by UnitedHealthcare.  \nAll other trademarks are the property of their r","cbCaiouGAzCGjisk","https://ap.wps.com/l/cbCaiouGAzCGjisk","pdf",215417,"English","# Part A: Individual’s information\n# Part B: Person who will get my information\n# Part C: Description of information to be shared\n# Part D: Purpose of disclosure\n# Part E: Expiration\n# Part F: Signature\n# Personal representatives\n# Instructions for Completion","[{\"question\":\"Who can use this HIPAA authorization form, and what does it allow?\",\"answer\":\"The form is completed and signed by the individual or a personal representative to allow UnitedHealthcare to share the person’s protected health information with the listed recipient.\"},{\"question\":\"How do I choose what information will be shared?\",\"answer\":\"Select one option under Part C: either all information, all information except specific categories, or only the specific information you authorize.\"},{\"question\":\"When does the authorization expire and what happens after signing?\",\"answer\":\"The authorization expires 24 months from the signature date unless an earlier date is provided or state rules require a shorter period. Signing is voluntary, and you may end the authorization at any time in writing without affecting sharing that already occurred.\"}]","HIPAA Authorization for the Use and Disclosure of Health Information | PDF",1789633421]