What is a HIPAA Authorization to Release Medical Information Form?

Under the HIPAA regulations, before protected health information (PHI) can be shared among providers or within a provider’s workforce, a signed release form must be obtained from a patient. The name of this signed release form is the HIPAA Authorization to Release Medical Information Form. Learn more about this medical records release form here.

A signed HIPAA Authorization to Release Medical Information Form (often referred to as a “release form”) is not required in the case of routine disclosures for treatment, payment or healthcare operations permitted by the HIPAA Privacy Rule.

HIPAA Authorization to Release Medical Information

What Must be in a HIPAA Authorization to Release Medical Information Form?

For a HIPAA Authorization to Release Medical Information Form to be compliant with the HIPAA Privacy Rule, the following information must be on the form:

  • A description of the information that will be used or disclosed.
  • A description of the purpose for which the information will be disclosed.
  • The name of the person or entity to whom the information will be disclosed.
  • An expiration date or expiration event when consent to use or disclose the information is withdrawn.
    • For example, an expiration event may be when a particular research study is completed.
    • An expiration date or an expiration event that relates to the individual or the purpose of the use or disclosure. 
  • The signature of the individual, and the date. 

The HIPAA authorization to release medical information form must also include statements adequate to place the individual on notice of all of the following:

  • The individual‘s right to revoke the authorization in writing
  • The exceptions to the right to revoke. 
    • Note: An individual may revoke an authorization in writing except when the covered entity has taken action in reliance on the authorization).
  • The covered entity may not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization, except that: 
    • A covered health care provider may condition the provision of research-related treatment on provision of an authorization for such research
    • A health plan may, to make eligibility or enrollment determinations, may condition enrollment in the health plan or eligibility for benefits on provision of an authorization.
  • The potential for information disclosed in to the authorization to be subject to redisclosure by the recipient and no longer be protected by the Privacy Rule

A HIPAA Authorization to Release Medical Information Form must be written in plain language. In addition, a copy of the signed authorization for release of medical records form should be provided to the patient.

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