[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-194903-105":53,"doc-detail-194903-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","hipaa-authorization-form","HIPAA Authorization Form","","HIPAA Authorization Form provides a structured consent framework authorizing a covered entity to use or disclose protected health information (PHI) that identifies an individual for a specified research study. The template includes fields for the research title, IRB project number, and research purpose, and it describes what categories of information may be used or disclosed. It also covers required participant-access listing, legal protection obligations, potential limitations on conditioning treatment, revocation rights, and optional statements regarding law-required disclosures and publication anonymity.",{"@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-form/194903/",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-form/194903.png","ImageObject",442,249,{"name":88,"@type":89},"Jiven","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/vnd.openxmlformats-officedocument.wordprocessingml.document","2026-10-05","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":47},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does signing this HIPAA Authorization Form allow?","Question",{"text":108,"@type":109},"Signing authorizes the named covered entity (and permitted persons or classes through it) to use and/or disclose health information that identifies you for the described research study.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What information can be used or disclosed for the research?",{"text":113,"@type":109},"The authorization describes the specific types of health information that may be used or disclosed for the study, such as medical record information, exam results, medical history, lab tests, and related condition information.",{"name":115,"@type":106,"acceptedAnswer":116},"Can you revoke this authorization, and what happens after revocation?",{"text":117,"@type":109},"You can change your mind and revoke the authorization at any time in the applicable scenario. Revocation must be written to the covered entity, and even after revocation, already obtained information may still be used or disclosed as needed to maintain research integrity.","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},194903,1788443774,{"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":47,"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":125,"read_time":9},1099513958607,"https://ap-avatar.wpscdn.com/avatar/100002390cf8733938c?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778829742770036399","HIPAA Authorization Form\nThis is a template. Remove all help text before submitting to the IRB and check formatting.\nAuthorization to Use or Disclose (Release) Health Information that                                          Identifies You for a Research Study\nIf you sign this document, you give permission for [name or other identification of specific health care provider(s) or description of classes of persons, e.g., all doctors, all health care providers] at [name of covered entity or entities] to use or disclose (release) your health information that identifies you for the research study described here:\nTitle: Insert title\nIRB Project Number: Insert IRB project number\nDescription of Research: Insert brief description of research purpose\nThe information that we may use or disclose (release) for this research includes [Provide a description of information to be used or disclosed for the research project. This may include, for example, all information in a medical record, results of physical examinations, medical history, lab tests, or certain health information indicating or relating to a particular condition.]\nThe health information listed above may be used by and/or disclosed (released) to:\nWhere a covered entity conducts the research study, the Authorization must list ALL names or other identification, or ALL classes, of persons who will have access through the covered entity to the protected health information (PHI) for the research study (e.g., research collaborators, sponsors, and others who will have access to data that includes PHI). Examples may include, but are not limited to the following:\nData coordinating centers that will receive and process PHI;\nSponsors who want access to PHI or who will actually own the research data; and/or\nInstitutional Review Boards or Data Safety and Monitoring Boards.\nIf the research study is conducted by an entity other than the covered entity, the authorization need only list the name or other identification of the outside researcher (or class of researchers) and any other entity to whom the covered entity is expected to make the disclosure.\n[Name of covered entity] is required by law to protect your health information. By signing this document, you authorize [name of covered entity] to use and/or disclose (release) your health information for this research. Those persons who receive your health information may not be required by Federal privacy laws (such as the Privacy Rule) to protect it and may share your information with others without your permission, if permitted by laws governing them.\nPlease note that: [include the appropriate statement]\n(Insert when the research involves treatment and is conducted by the covered entity or when the covered entity provides health care solely for the purpose of creating protected health information to disclose to a researcher) You do not have to sign this Authorization, but if you do not, you may not receive research-related treatment.\n(Insert when the research does not involve research-related treatment by the covered entity or when the covered entity is not providing health care solely for the purpose of creating protected health information to disclose to a researcher) [Name of covered entity] may not condition (withhold or refuse) treating you on whether you sign this Authorization.\nPlease note that: [include the appropriate statement]\n(Insert where the research study is conducted by the covered entity) You may change your mind and revoke (take back) this Authorization at any time. Even if you revoke this Authorization, [name or class of persons at the covered entity involved in the research] may still use or disclose health information they already have obtained about you as necessary to maintain the integrity or reliability of the current research. To revoke this Authorization, you must write to: [name of the covered entity(ies) and contact information].\n(Insert where the research study is conducted by an entity other than the covered enti","cbCaidRr0pxoTSbX","https://ap.wps.com/l/cbCaidRr0pxoTSbX","docx",28118,"English","# Authorization to Use or Disclose Health Information for a Research Study\n## Research details\n## Information to be used or disclosed (PHI)\n## Who may access PHI through the covered entity\n## Legal protections and permitted sharing\n## Revocation and expiration\n## Optional elements","[{\"question\":\"What does signing this HIPAA Authorization Form allow?\",\"answer\":\"Signing authorizes the named covered entity (and permitted persons or classes through it) to use and/or disclose health information that identifies you for the described research study.\"},{\"question\":\"What information can be used or disclosed for the research?\",\"answer\":\"The authorization describes the specific types of health information that may be used or disclosed for the study, such as medical record information, exam results, medical history, lab tests, and related condition information.\"},{\"question\":\"Can you revoke this authorization, and what happens after revocation?\",\"answer\":\"You can change your mind and revoke the authorization at any time in the applicable scenario. Revocation must be written to the covered entity, and even after revocation, already obtained information may still be used or disclosed as needed to maintain research integrity.\"}]","HIPAA Authorization Form | DOCX"]