"HIPAA Consent Form"

What Is a HIPAA Consent Form?

A HIPAA Consent Form is a written authorization completed by the patient who lets their medical provider disclose health information to the individual or organization named in the document. The patient may present this consent form to their current healthcare provider and ask them to disclose protected health information.

Alternate Name:

  • HIPAA Patient Consent Form.

Download a printable HIPAA Consent Form template through the link below.

This document will share your health records, results of physical examinations and laboratory tests, X-ray reports, and financial documentation related to your treatment with people you trust.

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How to Write a HIPAA Consent Form?

Traditionally, a HIPAA Consent Form sample is provided by the medical facility to the patient at the latter's request. It can then be personalized - for example, the patient adds their name and the name of the individual who will get access to their medical history and treatment.

If you have to create a document from scratch, follow these steps to prepare a HIPAA Patient Consent Form:

  1. Write down your full name and identify the healthcare provider.
  2. Certify your consent to allow the healthcare provider to share the protected health information listed in the form with the person or organization that represents you. There are no limitations here - you can name your family member, friend, attorney, or religious mentor you can confide in. Add their contact information so that the hospital or clinic in question can reach out to them on your behalf.
  3. State the duration of the consent - the person can get access to your health information only within a specific period of time. Alternatively, you can provide an open-ended authorization.
  4. Outline the extent of the authorization. You may forbid the disclosure of certain facts as long as you specify them in the form - for instance, the patient is within their rights to exclude the consent to share mental health records, HIV and AIDS diagnosis and treatment details, or substance abuse treatment.
  5. Indicate the reasoning behind granting another person or organization the right to review your medical history and prognosis. You may name the physician you have known for a long time and who, in your opinion, will make the correct medical decision on your behalf if they learn about the treatment from your current medical provider.
  6. Confirm you know about your right to revoke the authorization at any time and you are making the decision to release your personal information voluntarily.
  7. Sign and date the consent form. To add an extra level of protection to your interests, you may prepare and sign the document before a notary public or witnesses.

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HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to
protect your privacy. We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide
services or to ensure that all administrative matters related to your care are handled
appropriately. This specifically includes the sharing of information with other
healthcare providers, laboratories, health insurance payers as is necessary and
appropriate for your care. Patient files may be stored in open file racks and will
not contain any coding which identifies a patient’s condition or information which
is not already a matter of public record. The normal course of providing care
means that such records may be left, at least temporarily, in administrative areas
such as the front office, examination room, etc. Those records will not be available
to persons other than office staff . You agree to the normal procedures utilized
within the office for the handling of charts, patient records, PHI and other
documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do
this by telephone, e-mail, U.S mail, or by any means convenient for the practice
and/or as requested by you. We may send you other communications informing
you of changes to office policy and new technology that you might find valuable
or informative.
3. The practice utilizes a number of vendors in the conduct of business. These
vendors may have access to PHI but must agree to abide by the confidentiality
rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents
which may include PHI by government agencies or insurance payers in normal
performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention
of the office manger or the doctor.
6. Your confidential information will not be used for the purposes of marketing or
advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state
and federal laws.
© ​
T EMPLATEROLLER.COM
HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to
protect your privacy. We have adopted the following policies:
1. Patient information will be kept confidential except as is necessary to provide
services or to ensure that all administrative matters related to your care are handled
appropriately. This specifically includes the sharing of information with other
healthcare providers, laboratories, health insurance payers as is necessary and
appropriate for your care. Patient files may be stored in open file racks and will
not contain any coding which identifies a patient’s condition or information which
is not already a matter of public record. The normal course of providing care
means that such records may be left, at least temporarily, in administrative areas
such as the front office, examination room, etc. Those records will not be available
to persons other than office staff . You agree to the normal procedures utilized
within the office for the handling of charts, patient records, PHI and other
documents or information.
2. It is the policy of this office to remind patients of their appointments. We may do
this by telephone, e-mail, U.S mail, or by any means convenient for the practice
and/or as requested by you. We may send you other communications informing
you of changes to office policy and new technology that you might find valuable
or informative.
3. The practice utilizes a number of vendors in the conduct of business. These
vendors may have access to PHI but must agree to abide by the confidentiality
rules of HIPAA.
4. You understand and agree to inspections of the office and review of documents
which may include PHI by government agencies or insurance payers in normal
performance of their duties.
5. You agree to bring any concerns or complaints regarding privacy to the attention
of the office manger or the doctor.
6. Your confidential information will not be used for the purposes of marketing or
advertising of products, goods or services.
7. We agree to provide patients with access to their records in accordance with state
and federal laws.
© ​
T EMPLATEROLLER.COM
8. We may change, add, delete or modify any of these provisions to better serve the
needs of the both the practice and the patient.
9. You have the right to request restrictions in the use of your protected health
information and to request change in certain policies used within the office
concerning your PHI. However, we are not obligated to alter internal policies to
conform to your request.
I, ___________________, on ___________________, hereby consent and acknowledge
my agreement to the terms set forth in this HIPAA Consent Form and any subsequent
changes in office policy. I understand that this consent shall remain in force from this
time forward.
© ​
T EMPLATEROLLER.COM
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