Template library · Consent & legal
HIPAA Privacy Authorization template
Authorization form allowing disclosure of protected health information to a named party.
- 12 fields across 5 sections
- Included with MyWellOps
- Edit it, or save your own version
What’s in it
- Client full nameText
- Practice nameText
- The client named above authorizes the practice named above to release the protected health information (PHI) described below.
Information to Be Released
- Other information to be releasedText
- Dates of service
- Diagnosis / assessment summary
- Treatment plan and progress notes
- Medication records
Purpose of Release
- Purpose of ReleaseChoice
Released To
- NameText
- Relationship / roleText
- Address or faxText
Expiration
- Authorization expires onDate
- This authorization expires on the date above, or upon written revocation, whichever occurs first.
Your Rights
- Client signatureSignature
- Date signed (client)Date
- Witness / therapist signatureSignature
- Date signed (witness)Date
- You may revoke this authorization at any time in writing, except to the extent that information has already been released.
- Releasing your records will not affect your ability to receive treatment, payment, or enrollment in services.
- Information released may be re-disclosed by the recipient and no longer protected by HIPAA.
When to use it
Use a consent form before treatment starts, and again when what you are doing changes, so the client’s agreement is recorded in writing alongside their notes.
How it works in MyWellOps
- Edit the wording to match your service and your professional body’s guidance.
- Send it to the client to read and sign in their client portal; if it isn’t signed, they get an email reminder after 3 days.
- The signed copy stays on the client’s record.
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