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The form collects patient/insured details, specifies which documents or dates of service may be released (including options for providers or health plans), and identifies any special limitations such as exclusions for HIV/AIDS test results. It also lists the disclosing provider/plan, the recipient persons or organizations, the purpose of disclosure, and the expiration date or event. Rights are explained, including revocation and re-disclosure risk after release.",{"@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/nebraska-hipaa-authorization-form-health-information-use-and-disclosure/283938/",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/nebraska-hipaa-authorization-form-health-information-use-and-disclosure/283938.png","ImageObject",442,249,{"name":88,"@type":89},"Gloria","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-11-03","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",22,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must be provided about the patient/insured?","Question",{"text":109,"@type":110},"The form requests the patient/insured’s name, date of birth, address, phone number, and account or policy number if known.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What personal health information can be authorized for disclosure?",{"text":114,"@type":110},"The form allows selection of specific documents or dates of service, with different options for a provider or for a health plan (including items such as discharge summaries, lab results, claims records, or the entire medical record).",{"name":116,"@type":107,"acceptedAnswer":117},"How does expiration and revocation work under this authorization?",{"text":118,"@type":110},"The authorization expires on a specified date or event, and periods longer than 180 days may not be accepted. The signer can revoke at any time in writing to the disclosing provider/plan, but revocation does not affect disclosures already made or actions already taken in reliance on the authorization.","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},283938,1790219781,{"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":73,"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":140,"read_time":9},2336474459895,"https://ap-avatar.wpscdn.com/avatar/22000baeef7a5ed0655?x-image-process=image/resize,m_fixed,w_180,h_180&k=1786071322749376916","HIPAA AUTHORIZATION FOR USE AND DISCLOSURE  \nBY SIGNING THIS FORM, YOU PERMIT THE HEALTH CARE PROVIDER(S)/HEALTH PLAN(S) IDENTIFIED BELOW TO DISCLOSE YOUR CONFIDENTIAL PERSONAL HEALTH INFORMATION  \n1.  PATIENT/INSURED. The patient/insured whose information may be released is:  \nNAME   D.O.B.  ADDRESS   PHONE \\# ACCOUNT OR POLICY \\# (if known)   \n2.  PERSONAL HEALTH INFORMATION. Disclose the following documents or dates of service (be specific)    \nOR  \nIf Provider:  \n☐ Discharge summary- ☐ Face sheet ☐ H&P/consultation- ☐ Progress notes ☐ ER record- ☐ Operative report ☐ X-rays and other films- ☐ Lab results ☐ Itemized statement- ☐ Billing records ☐ Entire medical record  \nIf Health Plan:  \n☐ My enrollment/application record ☐ My premium payment/billing record  \n☐ My claims record (claim \\#:  )☐ My medical record  \n3.  SPECIAL LIMITATIONS. Does this Authorization exclude (check all that apply):  \n☐ HIV/AIDS test results (if part of the specified record)  \n☐ Other exclusions (be specific)    \n4.  DISCLOSING PROVIDER/PLAN. The following provider(s)/plan(s) may disclose the personal health information:  \nProvider/Plan   Address   Phone   \n5.  RECIPIENT  . The following persons or organizations are to receive the personal health information:  \nName   Phone   Address    \n6.  PURPOSE OF DISCLOSURE. The reason I am authorizing release is:  \n☐ My request ☐ Other (describe):    \n7.  EXPIRATION. This Authorization expires (periods longer than 180 days may not be accepted):  \nDate:   OR Event:    \n8.  EXPLANATION OF RIGHTS. I understand that:  \nÿ I can revoke this Authorization at any time by giving my written revocation to the Disclosing Provider/Plan.  \nMy revocation is not effective as to disclosures already made and actions already taken in reliance upon this Authorization.  \nÿ The disclosing provider/plan may NOT condition treatment, enrollment in the health plan or eligibility for benefits on whether I sign this Authorization.  \nÿ I am authorizing disclosure of information protected under federal law. This information, once disclosed, may be subject to re-disclosure by the recipient and no longer be protected by state or federal law.  \nSignature of Patient/Insured or Personal Representative Date  \nRepresentative’s Relationship to Patient/Insured (if applicable) Representative’s Printed Name  \nUse of this form does not assure acceptance by provider or health plan. This form is not to be interpreted as the standard HIPAA authorization for Nebraska. (See “Explanation and Instructions” on reverse side)  \nForm Made Fillable by eForms  \nEXPLANATION AND INSTRUCTIONS  \n1. Explanation. The administrative simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. §§ 1320d to d-7, and the privacy regulations issued thereunder at 45 C. F. R. §§ 160.101 et seq. and 164.501 et seq. impose many new privacy duties on covered health care providers (doctors, hospitals, nursing homes, pharmacies, physical therapists, etc. ) and health plans (typically insurers and group health plans offering health, dental, vision, Medicare supplemental and long-term care coverage) . Under HIPAA, before a covered provider/plan may disclose protected health information based on a patient’s/insured’s authorization or the authorization of a “personal representative,” the authorization form itself must meet specific (often new) content requirements. Specifically, see 45 C. F. R. § 164.508, the rule governing required content of authorizations.  \nThe purpose of this form is to give lawyers and others a standard form which covered health care providers and plans in Nebraska should accept. Note that if you are dealing with a specific provider or plan, you can always obtain and use their pre-printed form and thereby be assured they will not object to the form of the authorization. Use this form to: (i) to obtain protected health information (a medical record or a health care billing record, for example) from a provider or","cbCainnNZM81afuZ","https://ap.wps.com/l/cbCainnNZM81afuZ","pdf",126952,"English","# HIPAA Authorization for Use and Disclosure\n## Patient/Insured Information\n## Personal Health Information to Be Disclosed\n## Special Limitations\n## Disclosing Provider/Plan\n## Recipient of Information\n## Purpose of Disclosure\n## Expiration\n## Explanation of Rights\n## Explanation and Instructions","[{\"question\":\"What information must be provided about the patient/insured?\",\"answer\":\"The form requests the patient/insured’s name, date of birth, address, phone number, and account or policy number if known.\"},{\"question\":\"What personal health information can be authorized for disclosure?\",\"answer\":\"The form allows selection of specific documents or dates of service, with different options for a provider or for a health plan (including items such as discharge summaries, lab results, claims records, or the entire medical record).\"},{\"question\":\"How does expiration and revocation work under this authorization?\",\"answer\":\"The authorization expires on a specified date or event, and periods longer than 180 days may not be accepted. The signer can revoke at any time in writing to the disclosing provider/plan, but revocation does not affect disclosures already made or actions already taken in reliance on the authorization.\"}]","Nebraska HIPAA Authorization Form - Health Information Use and Disclosure | PDF",1789622852]