HIPAA Authorization Form Template
The HIPAA Authorization Form Template authorizes the use or disclosure of protected health information. By signing this form, the individual understands that he/she may revoke authorization at any time by notifying the healthcare provider in writing. The revocation will only be effective from the date it is received in the office and will not apply retroactively. MDO109-1 HIPAA AUTHORIZATION FORM and the information requested should be kept in each record.
The Office Manager should adopt a written privacy procedure that clearly identifies employees or classes of employees who require access to protected information, how it will be used within the entity, and when the information may be disclosed. To protect patient privacy, employees must take extra precautions, both in structures and in circumstances, not to inadvertently release patient information. Patients may choose to deny the provider from using their information for a variety of reasons. Patients can opt out of any portion of the notice.
Format: Microsoft Word 2013 (.docx)
Manual: Medical Office
Procedure: Health Insurance Portability Accountability Procedure MDO109