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It captures requester and recipient identity details, the relationship, contact information, and the specific purpose for the authorization, including medical care, personal matters, legal action, physician changes, research, or third-party disclosure. It also lists categories of information that may be released, specifies special-permission records where required, and defines an expiration date or defaults to six months. The form includes signature, witness provisions, and agency-use fields for processing requests.",{"@graph":63,"@context":119},[64,80,102],{"@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/louisiana-authorization-hipaa-release-or-obtain-health-information/244762/",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/louisiana-authorization-hipaa-release-or-obtain-health-information/244762.png","ImageObject",442,249,{"name":88,"@type":89},"Genevieve","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-12",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",13,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information can be released or obtained using this Louisiana HIPAA authorization form?","Question",{"text":109,"@type":110},"The form allows selection of categories such as an entire record, medical history and examinations, surgical reports, treatment or tests, prescriptions, immunizations, hospital and laboratory records, and imaging reports. It also supports additional options if listed.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How is the purpose of the authorization determined?",{"text":114,"@type":110},"The signer places an “X” in the box(es) that apply, such as further medical care, personal use, legal investigation or action, changing physicians, research related treatment, or creating health information for disclosure to a third party.",{"name":116,"@type":107,"acceptedAnswer":117},"When does the authorization expire?",{"text":118,"@type":110},"The signer specifies a date or event. If no expiration date is provided, the authorization expires six months from the date it was signed.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},244762,1789221560,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":4},1374391974585,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","Louisiana Authorization (HIPAA) to Release or Obtain Health Information  \n(including paper, oral and electronic information)  \n\n| Name | Request Date |\n| --- | --- |\n| Mailing Address | Date ofBirth |\n| City/State/Zip | Medicaid \\# or Social Security \\# |\n| I authorize:\u003Cbr>Name:   Mailing Address:   City, State, Zip Code:  \u003Cbr>Relationship:   Telephone Number: \u003Cbr>􀂈 TO RELEASE Information TO OR 􀂈 TO OBTAIN Information FROM\u003Cbr>(Place an “X” in the box that indicates if the information is being released OR requested.) Name:   Mailing Address:   City, State, Zip Code:   Relationship:   Telephone Number:  |  |\n\nThe Purpose of this Authorization is indicated in the box(es) below. (Place an “X” in the box(es) that apply.)  \n􀂈 Further Medical Care 􀂈 Personal 􀂈 Legal Investigation or Action 􀂈 Changing Physicians  \n􀂈 Research related treatment 􀂈 Creating health information for disclosure to a third party.  \n􀂈 Other: (Specify)   \nI authorize the release of the following protected health information.  \n(Place an “X”in the box(es) that apply to the information you want released or you want to obtain.)  \n􀂈 Entire Record 􀂈 Medical History, Examination, Reports 􀂈 Surgical Reports 􀂈 Treatment or Tests  \n􀂈 Prescriptions 􀂈 Immunizations 􀂈 Hospital Records including Reports 􀂈 Laboratory Reports  \n􀂈 X-ray Reports 􀂈 MR/DD Records 􀂈 Other:    \nIn compliance with state and/or federal laws which require special permission to release otherwise privileged information, please release the following records.  \n􀂈 Alcoholism † 􀂈 Drug Abuse † 􀂈 Mental Health 􀂈Vocational Rehabilitation 􀂈 HIV (AIDS)  \n􀂈 Sexually Transmitted Diseases 􀂈 Genetics 􀂈 Psychotherapy Notes  \n􀂈 Other   \nThis authorization shall expire on   (date or event) and is needed for the period beginning   and ending   .  \nI understand that if I do not specify an expiration date, this authorization will expire six (6) months from the date on which it was signed. I acknowledge that I have read both pages 1 and 2 of this form.  \nSignature of Individual or Personal Representative Authorized by Law Date  \nSignature of Witness (If signed with an “X” or mark) Date  \nFor LDH Use When Requesting Records  \nI am authorized to receive this disclosure. Documentation on the above Personal Representative has been obtained.  \nSignature and Title of Agency Representative Date  \n† Provider shall be given a copy of signed document that acknowledges their receipt of Federal Rule 42 CFR § 2.32-Prohibition on redisclosure.  \nHIPAA 402P  \nPage 1 of 1  \nForm Made Fillable by eForms","cbCaiqVGMjJSapoc","https://ap.wps.com/l/cbCaiqVGMjJSapoc","pdf",369627,"English","# Authorization Details\n## Purpose of Authorization\n## Types of Protected Health Information\n## Special Permission Records\n## Expiration and Signatures","[{\"question\":\"What information can be released or obtained using this Louisiana HIPAA authorization form?\",\"answer\":\"The form allows selection of categories such as an entire record, medical history and examinations, surgical reports, treatment or tests, prescriptions, immunizations, hospital and laboratory records, and imaging reports. It also supports additional options if listed.\"},{\"question\":\"How is the purpose of the authorization determined?\",\"answer\":\"The signer places an “X” in the box(es) that apply, such as further medical care, personal use, legal investigation or action, changing physicians, research related treatment, or creating health information for disclosure to a third party.\"},{\"question\":\"When does the authorization expire?\",\"answer\":\"The signer specifies a date or event. If no expiration date is provided, the authorization expires six months from the date it was signed.\"}]","Louisiana Authorization (HIPAA) - Release or Obtain Health Information | PDF"]