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The form also defines authorization expiration, explains revocation rights and limits, and requires signatures with dates and optional translator information.",{"@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-v1-pdf-release-form/283686/",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-v1-pdf-release-form/283686.png","ImageObject",442,249,{"name":42,"@type":43},"Berry Peter","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-28","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",14,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information is required from the patient or plan member?","Question",{"text":63,"@type":64},"The form requires last name, first name, middle name, reference number, date of birth, and address details, plus applicable page instructions for completing all sections and using N/A when not applicable.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Who can disclose and who can receive the protected health information (PHI)?",{"text":68,"@type":64},"Section 2 identifies the individual/organization authorized to disclose PHI, and Section 3 identifies the individual/organization authorized to receive PHI, including their names, relationship (for the receiver), and contact/address information.",{"name":70,"@type":61,"acceptedAnswer":71},"How does revocation and expiration work for this authorization?",{"text":72,"@type":64},"Unless revoked, authorization expires on the specified event or date in Section 4, with N/A used for ongoing releases. The patient/plan member may revoke the authorization in writing submitted to the party specified in Section 2, which prevents further disclosure from the date of receipt, while not affecting actions taken in reliance on a valid authorization.","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},283686,1790456187,{"code":4,"msg":82,"data":83},"success",[84,89,94,98,103,108,112,117,122],{"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":55,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},"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":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":33,"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":139,"read_time":26},1374402524268,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","HIPAA Authorization Form  \nAUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION  \nPlease complete all sections of this HIPAA Authorization Form. If any sections are left blank, this form will be invalid. Use N/A if not applicable. (Page 1 of 4)  \n\n| Section 1 – Patient/Plan Member Information |\n| --- |\n| Last Name:   First Name:   Middle Name:   Reference Nº:   Date of Birth:   Address:   City/State/ZIP:   |\n\n\n| Section 2- Individual/Organization Authorized by Signatory to Disclose PHI |\n| --- |\n| Name:   Address:   City/State/ZIP:   |\n\n\n| Section 3- Individual/Organization Authorized by Signatory to Receive PHI |\n| --- |\n| Name:   Relationship to Patient/Plan Member:  Telephone Nº:   Address:   City/State/ZIP:   |\n\n\n| Section 4-Authorization Expiration Event or Date |\n| --- |\n| Unless otherwise revoked by the patient/plan member, this authorization for the release of PHI to the above-named individual/organization will expire on the event or date specified below. Enter N/A in both fields if the release is ongoing.\u003Cbr>Expiration Event:   Expiration Date:   |\n\nHIPAA Authorization Form  \nAUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION  \nPlease complete all sections of this HIPAA Authorization Form. If any sections are left blank, this form will be invalid. Use N/A if not applicable. (Page 2 of 4)  \n\n| Section 5 – Health Information to be Disclosed-General |\n| --- |\n| I authorize the following Protected Health Information to be disclosed:\u003Cbr>q Medical Records q Dental Records q Other Non-Specific\u003Cbr>If Other Non-Specific, provide details:  |\n\n\n| Section 6 – Health Information to be Disclosed – Specific |\n| --- |\n| I authorize the following Protected Health Information to be disclosed:\u003Cbr>q Communicable Disease Signature:   Date:  \u003Cbr>q Reproductive Health Signature:   Date:  \u003Cbr>q HIV Test Results Signature:   Date:  \u003Cbr>q Mental Health Records * Signature:   Date:  \u003Cbr>q Substance Use Disorder Signature:   Date:  \u003Cbr>q Other Signature:   Date:   If \"Other\", provide details:  \u003Cbr>* Requests for psychotherapy notes require a separate HIPAA Authorization Form and may not be combined with any other request .\u003Cbr>q Psychotherapy Notes Signature:   Date:   |\n\n\n| Section 7-Purpose of the Release or Use of Health Information |\n| --- |\n| q Healthcare q Research q Marketing q Sale q Legal\u003Cbr>q Other (please specify):   Note: The sale of PHI authorized by this HIPAA Authorization Form will result in remuneration to the party specified in Section 2. |\n\nHIPAA Authorization Form  \nAUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION  \nPlease complete all sections of this HIPAA Authorization Form. If any sections are left blank, this form will be invalid. Use N/A if not applicable. (Page 3 of 4)  \n\n| Section 8-Authorization Information |\n| --- |\n| I understand the following:\u003Cbr>1. I authorize the use or disclosure of Protected Health Information as described above for the purpose indicated until such event or time as specified in Section 4.\u003Cbr>2. I have the right to revoke this authorization. To do so I understand I must submit my revocation in writing to the party specified in Section 2. The revocation will prevent further disclosure of my health information by the party specified in Section\u003Cbr>2 from the date of receipt. I understand a delay may exist if the party specified in Section 2 is not the covered entity authorized to disclose Protected Health Information to the party specified in Section 2. I also understand that a written revocation is not effective with respect to actions the covered entity or party specified in Section 2 took in reliance on a valid Authorization, or where the Authorization was obtained as a condition of obtaining insurance coverage.\u003Cbr>3. I am signing this authorization voluntarily and understand my entitlement to treatment, payment, enrollment, or eligibility for health plan benefits will not be affected if I do not sign this HIPAA Authorization Form.\u003Cbr>4. If the party specified in","cbCailW7tpMvfy7h","https://ap.wps.com/l/cbCailW7tpMvfy7h","pdf",149802,"English","# HIPAA Authorization Form\n## Patient/Plan Member Information\n## Authorized to Disclose PHI\n## Authorized to Receive PHI\n## Authorization Expiration Event or Date\n## Health Information to Be Disclosed (General)\n## Health Information to Be Disclosed (Specific)\n## Purpose of the Release or Use of Health Information\n## Authorization Information (Rights and Conditions)\n## Additional Conditions\n## Signature by Patient/Plan Member","[{\"question\":\"What information is required from the patient or plan member?\",\"answer\":\"The form requires last name, first name, middle name, reference number, date of birth, and address details, plus applicable page instructions for completing all sections and using N/A when not applicable.\"},{\"question\":\"Who can disclose and who can receive the protected health information (PHI)?\",\"answer\":\"Section 2 identifies the individual/organization authorized to disclose PHI, and Section 3 identifies the individual/organization authorized to receive PHI, including their names, relationship (for the receiver), and contact/address information.\"},{\"question\":\"How does revocation and expiration work for this authorization?\",\"answer\":\"Unless revoked, authorization expires on the specified event or date in Section 4, with N/A used for ongoing releases. The patient/plan member may revoke the authorization in writing submitted to the party specified in Section 2, which prevents further disclosure from the date of receipt, while not affecting actions taken in reliance on a valid authorization.\"}]","HIPAA Authorization Form - v1 - PDF release form | PDF",1789617259]