[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-294922-105":3,"detail-sidebar-cat-1-en-105":80,"doc-detail-294922-en":126},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":73,"head_meta":75,"extra_data":77,"updated_unix":79},105,"en","hipaa-authorization-for-use-or-disclosure-of-health-information-form","HIPAA Authorization for Use or Disclosure of Health Information - Form","","HIPAA Authorization for Use or Disclosure of Health Information template used to permit a covered party to use or disclose specified health information. It collects patient identification details, defines the information to be released, the authorized recipient, and the purpose(s) for the authorization, including marketing or sale where applicable. The form states when authorization ends and explains rights, including revocation limits, redisclosure risk, and signature requirements. Separate consent sections cover certain sensitive conditions and HIV/AIDS.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/hipaa-authorization-for-use-or-disclosure-of-health-information-form/294922/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/hipaa-authorization-for-use-or-disclosure-of-health-information-form/294922.png","ImageObject",442,249,{"name":42,"@type":43},"Caleb Sterling","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-23","2026-09-18",true,{"@type":52,"interactionType":53,"userInteractionCount":33},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"What health information can the patient authorize for release?","Question",{"text":62,"@type":63},"The patient can authorize disclosure of all health information or only information related to a specific treatment or condition, optionally covering a defined date range or other specified scope.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"How can the patient revoke this HIPAA authorization?",{"text":67,"@type":63},"Revocation must be in writing and sent to the appropriate disclosing party. Revocation is not possible for uses or disclosures already made based on the original permission, and insurance-related authorization may limit revocation.",{"name":69,"@type":60,"acceptedAnswer":70},"When is separate consent required?",{"text":71,"@type":63},"Separate consent is required to release information related to certain conditions such as physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment, and also for HIV testing and/or AIDS diagnosis or treatment.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},294922,1789711244,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,112,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":110,"slug":111},17,40,"forms",{"id":113,"doc_module":22,"doc_module_name":25,"category_name":114,"show_sort_weight":115,"slug":116},18,"Letters",30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":109,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":33,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":30,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":22},962084925290,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","HIPAA AUTHORIZATION FOR USE OR DISCLOSURE  \nOF HEALTH INFORMATION  \nThis form is for use when such authorization is required and complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Standards.  \nPrint Name of Patient:    \nDate of Birth:   SSN:    \nI. My Authorization  \nI authorize the following using or disclosing party:  \nto use or disclose the following health information.  \n☐ -All of my health information  \n☐ -My health information relating to the following treatment or condition:  \n☐ -My health information covering the period from   (date) to   (date)☐ -Other:    \nThe above party may disclose this health information to the following recipient:  \nName (or title) and organization   Address   City   State   Zip   Phone   Fax   Email    \nThe purpose of this authorization is (check all that apply) :  \n☐ -At my request  \n☐ -Other:    \n☐ -To authorize the using or disclosing party to communicate with me for marketing purposes when they receive payment from a third party to do so.  \n☐ -To authorize the using or disclosing party to sell my health information. I understand that theseller will receive compensation for my health information and will stop any future sales if I revoke this authorization.  \nThis authorization ends:  \n☐ -On (date)   \n☐ -When the following event occurs:    \nII. My Rights  \nI understand that I have the right to revoke this authorization, in writing, at any time, except where uses or disclosures have already been made based upon my original permission. I may not be able to revoke this authorization if its purpose was to obtain insurance. In order to revoke this authorization, I must do so in writing and send it to the appropriate disclosing party.  \nI understand that uses and disclosures already made based upon my original permission cannot be taken back.  \nI understand that it is possible that information used or disclosed with my permission may be redisclosed by the recipient and is no longer protected by the HIPAA Privacy Standards.  \nI understand that treatment by any party may not be conditioned upon my signing of this authorization (unless treatment is sought only to create health information for a third party or to take part in a research study) and that I may have the right to refuse to sign this authorization.  \nI will receive a copy of this authorization after I have signed it. A copy of this authorization is as valid as the original.  \nSignature of Patient:    \nDate:    \nIf the patient is a minor or unable to sign, please complete the following:  \n☐ -Patient is a minor:   years of age  \n☐ -Patient is unable to sign because:   Signature of Authorized Representative:    \nDate:  \n_________________  \nPrint Name of Authorized Representative:    \nAuthority of representative to sign on behalf of the patient:  \n☐ -Parent ☐ -Legal Guardian ☐ -Court Order ☐ -Other:    \nIII. Additional Consent for Certain Conditions  \nThis medical record may contain information about physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment. Separate consent must be given before this information can be released.  \n☐ - I consent to have the above information released.  \n☐ - I do not consent to have the above information released.  \nSignature of Patient or Authorized Representative:    \nDate:   Time:    \nIV. Additional Consent for HIV/AIDS  \nThis medical record may contain information concerning HIV testing and/or AIDS diagnosis or treatment. Separate consent must be given to have this information released.  \n☐ - I consent to have the above information released.  \n☐ - I do not consent to have the above information released.  \nSignature of Patient or Authorized Representative:    \nDate:   Time:","cbCaiiyZXd1WWOXH","https://ap.wps.com/l/cbCaiiyZXd1WWOXH","pdf",59022,"English","# I. My Authorization\n## II. My Rights\n# III. Additional Consent for Certain Conditions\n# IV. Additional Consent for HIV/AIDS","[{\"question\":\"What health information can the patient authorize for release?\",\"answer\":\"The patient can authorize disclosure of all health information or only information related to a specific treatment or condition, optionally covering a defined date range or other specified scope.\"},{\"question\":\"How can the patient revoke this HIPAA authorization?\",\"answer\":\"Revocation must be in writing and sent to the appropriate disclosing party. Revocation is not possible for uses or disclosures already made based on the original permission, and insurance-related authorization may limit revocation.\"},{\"question\":\"When is separate consent required?\",\"answer\":\"Separate consent is required to release information related to certain conditions such as physical or sexual abuse, alcoholism, drug abuse, sexually transmitted diseases, abortion, or mental health treatment, and also for HIV testing and/or AIDS diagnosis or treatment.\"}]","HIPAA Authorization for Use or Disclosure of Health Information - Form | PDF"]