Fillable Online 18534 - Authorization for Release of Information 2025

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The document is a Patient Authorization form for the release of Protected Health Information (PHI). It outlines the steps for patients to complete the form, including providing personal information, specifying who has the information, where it should be sent, and what specific health records are requested. The form also includes sections for special permissions, purpose of release, and preferred method of delivery. Additionally, it details the authorization and revocation process, emphasizing that a signature is required and that patients have rights regarding their health information.
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A HIPAA-compliant HIPAA release form must, at the very least, contain the following information: A description of the information that will be used/disclosed. The purpose for which the information will be disclosed. The name of the person or entity to whom the information will be disclosed.
These include: Patient Information: The authorization must clearly identify the individual whose information is being disclosed. Description of Information to be Disclosed: A detailed description of the information that will be shared. Purpose of Disclosure: The reason why the information is being disclosed.
Elements: A description of the PHI. The name of the person making the authorization. The name of the person or organization who is authorized to receive the PHI. A description of the purpose for the use or disclosure. An expiration date for the authorization. The signature of the person making the authorization.
Begin by specifying your name, the entity authorized to disclose information, and the individuals or entities you authorize to receive it. Indicate the specific information and purpose for which it will be disclosed, add an expiration date or event, and sign and date the form to confirm your consent.
Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.

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The Department adopts in paragraph (c)(1), the following core elements for a valid authorization: (1) a description of the information to be used or disclosed, (2) the identification of the persons or class of persons authorized to make the use or disclosure of the protected health information, (3) the identification
HIPAA authorization is consent obtained from a patient or health plan member that permits a covered entity or business associate to use or disclose PHI to an individual/entity for a purpose that would otherwise not be permitted by the HIPAA Privacy Rule.

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