Sample bHIPAA Authorizationb Form for Family MembersFriends I bb - americanbar 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the form. This identifies you as the individual granting authorization.
3. In the 'Name(s)' section, list the names of family members or friends who are authorized to access your health information.
4. Specify the relationship of each person listed to ensure clarity on who is receiving your information.
5. Next, check all applicable boxes under 'Health Information to be disclosed' to indicate what specific health records you are allowing to be shared.
6. If there are exceptions, check the appropriate boxes regarding mental health records, communicable diseases, or alcohol/drug abuse treatment.
7. Indicate how long this authorization will remain effective by checking either 'All past, present, and future periods' or specifying a date/event.
8. Finally, sign and date the form at the bottom to validate your authorization.

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