(Valid Authorization Under 45 CFR Chapter 164) 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your name in the 'Appointment of Authorized Recipients' section. List the individuals you authorize to access your health information.
3. In the 'Grant of Authority' section, specify which health care providers are permitted to disclose your medical information. Ensure you check all relevant categories, such as doctors and hospitals.
4. Review the 'Termination' clause carefully. Note that this authorization remains valid for two years after your death unless revoked in writing.
5. Complete the 'Re-disclosure' section by acknowledging that once your information is shared, it may not be protected under HIPAA.
6. Sign and date the document at the bottom. If required, have a notary public witness your signature for added validity.

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