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HIPAA-compliant Authorization Form (PDF) - MUSC Health

HIPAA-compliant Authorization Form (PDF) - MUSC Health 2026

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The document is an authorization form for the release of protected health information, requiring completion of patient details and specific instructions on how and where to send the information. It outlines the purpose of the release, types of information requested, and legal rights regarding the disclosure of medical records. The form emphasizes that signing is voluntary and provides contact information for further inquiries.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient Name, Date of Birth, and the last four digits of the SSN. This information is crucial for identifying the patient.
Fill in the Phone Number and MRN (if applicable). Ensure accuracy as this will be used for communication regarding the release.
Specify where you want the information sent by filling out the 'To' section with either an individual or organization’s details, including their address.
Indicate how you would like to receive the information by checking one of the options under 'Release Method / Format requested'.
In 'Information to be Released', check all relevant boxes that pertain to your request, ensuring you specify any particular documents needed.
Sign and date at the bottom of the form. If signed by a legal guardian, include their relationship to the patient.

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Versions	Form popularity	Fillable & printable
2022	4.1 Satisfied (52 Votes)
2021	4.9 Satisfied (25 Votes)
2019	4.3 Satisfied (60 Votes)
2019	4.4 Satisfied (128 Votes)
2017	4.1 Satisfied (41 Votes)
2017	4.3 Satisfied (46 Votes)

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is a HIPAA compliant authorization form?

A HIPAA authorization is a detailed document in which specific uses and disclosures of protected health are explained in full. By signing the authorization, an individual is giving consent to have their health information used or disclosed for the reasons stated on the authorization.

Do you have to agree to HIPAA authorization?

Verbal Consent or Acquiescence Required Disclosures to Family or Facility Directories. HIPAA generally requires an explicit HIPAA authorization that allows for the use and disclosure of protected health information. There are, however, instances where verbal consent can be utilized under HIPAA.

Do I have to give HIPAA authorization?

Authorization. A covered entity must obtain the individuals written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.

How to request medical records from musc?

If you are a patient of MUSC Health, select the MyChart link to access or create an account. Under the menu tab, click Request Medical Records.

What is authorization for release of health information pursuant to HIPAA oca official form no 960?

What is OCA official form No 960? OCA Form 960, Authorization to Release Health Information Pursuant to HIPAA, is a legal document signed by a patient that gives consent to the release of health information within the state of New York.

Is it OK to decline HIPAA authorization?

In addition to waivers of HIPAA during emergencies and disasters, the Privacy Rule also allows for waivers of HIPAA for research purposes specifically when an Institutional Review Board or Privacy Board authorizes a use or disclosure of PHI without the authorization of the patient to whom it relates.

When can HIPAA authorization be waived?

Authentication. A regulated entity must implement procedures to verify that a person seeking access to ePHI is who they say they are. 60. Transmission Security. A regulated entity must implement technical security measures to guard against unauthorized access to ePHI that is being transmitted over an electronic network