Federal and State Law, including the Health Insurance Portability and Accountability Act 2026

1. Click ‘Get Form’ to open it in the editor.
2. In Section A, enter the patient's full name, date of birth, telephone number, address, and last four digits of their Social Security Number.
3. Proceed to Section B and list the individual or organization authorized to view or discuss the PHI. Include their relationship to the patient and contact details.
4. In Section C, check the applicable boxes for the type of PHI that may be released: billing records, medical records, or both.
5. For Section D, indicate the dates of medical treatment relevant to this authorization by checking appropriate boxes and providing specific dates if necessary.
6. Select a purpose for disclosure in Section E from options like Claim, Continuing Care, Legal, Personal Use, or Other.
7. If acting on behalf of the patient, complete Section F with your details and attach proof of authority.
8. Review Sections G and H carefully before signing. Ensure all information is accurate before submitting.

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