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It collects member identity and contact details, the identity and relationship of authorized parties, the scope of PHI to be released, and the effective time period.",{"@graph":14,"@context":73},[15,34,56],{"@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-form-v031921-romans-1213-niv/283726/",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-form-v031921-romans-1213-niv/283726.png","ImageObject",442,249,{"name":42,"@type":43},"Aria","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-24","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",16,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What does this HIPAA Authorization allow?","Question",{"text":63,"@type":64},"It authorizes OneShare Health to share the member’s protected health information (PHI) with the individuals and/or organizations listed on the form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Does the authorization have an expiration date?",{"text":68,"@type":64},"Yes. It remains effective until a specified date or event; if left blank, it expires one year from the signature date.",{"name":70,"@type":61,"acceptedAnswer":71},"How can a member withdraw permission?",{"text":72,"@type":64},"A member can withdraw at any time by providing written notice of intent to revoke to the authorized parties listed above. Prior actions taken in reliance on the authorization will not be affected.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283726,1789618024,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,108,112,117,122],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":55,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},"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":82,"data":127},{"doc_id":79,"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":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"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":80,"read_time":22},2336464648322,"https://ap-avatar.wpscdn.com/avatar/2200025388227c56fec?_k=1778556882303663488","HIPAA Authorization  \nForm  \nAuthorization to Release Protected Health Information (PHI)  \nThis form is used for the authorization to use or disclose protected health information. Such authorization is required by the Health Insurance Portability and Accountability Act (HIPAA) .  \nBy completing and signing this form, I, or my legal representative, agree to allow OneShare Health to share my protected health information (PHI) with the person(s) and/or organization(s) listed below. I understand this authorization is voluntary and made to confirm my directions. I understand that once the information is disclosed, it may re-disclosed and no longer protected by federal privacy regulations. I hereby give permission for the disclosure of my personal health information (PHI) in the manner described below.  \n\n| Name of Member or Individual |  |\n| --- | --- |\n| First Name: | Last Name: |\n| Mailing Address: |  |\n| City, State, and Zip Code: |  |\n| Phone Number: | Date of Birth: |\n\nAuthorization Statement:  \nI hereby authorize the disclosure of my Protected Health Information when requested by me, or notification in the event of a medical emergency, to the individuals named below. I understand this authorization is voluntary and that refusal to sign will not affect my ability to obtain and retain membership.  \n\n| Authorized Parties and Relationship |  |\n| --- | --- |\n| Name: | Relationship: |\n| Name: | Relationship: |\n| Name: | Relationship: |\n\nI allow the above-mentioned person(s) to receive information related to (check one):  \n Disclose my complete health record (including but no limited to diagnosis, labs, tests, treatment, and billing for all conditions)  \n Disclose and/or allow changes to only the following portions of my health record (check as appropriate):  Billing Records and Membership Records  \n Change/Updated of Record  \n Mental Health Records  \n Alcohol/drug abuse treatment  \n Communicable diseases  \n Other:  \nEffective Time Period:  \nThis authorization is valid and shall be effective until   (date or event), unless cancelled prior. If this field is blank, the authorization expires one year from the date of the signature below.  \n“Share with the Lord’s people who are in need. Practice hospitality.”  \nHIPAA Authorization Form v.031921 Romans 12:13 (NIV) Confidential • 1  \nHIPAA Authorization  \nForm  \nRight to Revoke:  \nI understand that I can withdraw my permission at any time by giving written notice stating my intent to revoke this authorization to the person(s) or anization named above. I understand that prior actions taken in reliance on this authorization by entities that had permission to access my health information will not be affected.  \nSignature of Authorization:  \nI have read this form and agree to the uses and disclosures of the information as described. I understand that refusing to sign this form does not stop disclosure of health information that has occurred prior to revocation or that is otherwise permitted by law without my specific authorization or permission, including disclosures to covered entities as provided by 45 C. F. R. § 164.502(a)(1) .  \nSignature of Member or Legally Authorized Representative Date  \nONESHARE HEALTH, LLC (ONESHARE) IS NOT AN INSURANCE COMPANY BUT A RELIGIOUS HEALTH CARE SHARING MINISTRY (HCSM) THAT FACILITATES THE SHARING OF MEDICAL EXPENSES AMONG MEMBERS. As with all HCSMs under 26 USC § 5000A(d)(2)(B)(ii), OneShare’s members are exempt from the ACA individual mandate. OneShare does not assume any legal risk or obligation for payment of member medical expenses. Neither OneShare nor its members guarantee or promise that medical bills will be paid or shared by the membership. Available nationwide, but please [check](check www.onesharehealth.com/legal-notices)[ ](check www.onesharehealth.com/legal-notices)[www.onesharehealth.com/legal-notices](check www.onesharehealth.com/legal-notices) for the most up to date state availability listing.  \n“Share with the Lord’s people who are in ne","cbCaievi104dXB4M","https://ap.wps.com/l/cbCaievi104dXB4M","pdf",122490,"English","# HIPAA Authorization\n## Authorization to Release PHI\n## Authorized Parties and Relationship\n## Scope of Information Released\n## Effective Time Period\n## Right to Revoke and Signature","[{\"question\":\"What does this HIPAA Authorization allow?\",\"answer\":\"It authorizes OneShare Health to share the member’s protected health information (PHI) with the individuals and/or organizations listed on the form.\"},{\"question\":\"Does the authorization have an expiration date?\",\"answer\":\"Yes. It remains effective until a specified date or event; if left blank, it expires one year from the signature date.\"},{\"question\":\"How can a member withdraw permission?\",\"answer\":\"A member can withdraw at any time by providing written notice of intent to revoke to the authorized parties listed above. Prior actions taken in reliance on the authorization will not be affected.\"}]","HIPAA Authorization Form - v.031921 - Romans 12:13 (NIV) | PDF"]