Hipaa Compliant Authorization Form PDF Details

The HIPAA compliant authorization form is a document that provides permission for healthcare professionals to exchange protected health information (PHI) between each other and with third-party vendors. The form must be completed and signed by the individual who is authorizing the exchange of PHI. This guide explains the components of a HIPAA compliant authorization form, explains when it is needed, and provides tips for completing it accurately.

Listed here, you may find some specifics about hipaa compliant authorization form PDF. It is suggested that you read this material before you start working with the PDF.

Form NameHipaa Compliant Authorization Form
Form Length1 pages
Fillable fields27
Avg. time to fill out5 min 39 sec
Other nameshipaa authorization form pdf nj, nj hipaa authorization form, hipaa authorization form new jersey, hipaa compliant patient forms nj

Form Preview Example





Patient name:

Health Record Number



Date of Birth:


1.I authorize the use or disclosure of the above-named individual’s health information as described below:

2.The following individual or organization is authorized to make the disclosure:


3.The type and amount of information to be used or disclosed is as follows: (include dates where appropriate)

__XX_ ENTIRE RECORD – Duly Certified to be a TRUE & ACCURATE COMPLETE copy.

____ problem list



____ medication list



____ list of allergies



____ immunization record



____ most recent history and physical



____ most recent discharge summary



____ laboratory results



____ x-ray and imaging reports



____ consultation reports

from (doctors’ names)


____ other - ALL



4.I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndromes (AIDS) or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment for alcohol and drug abuse.

5.This information may be disclosed to and used by the following individual or organization

Goldsmith & Goldsmith 140 Sylvan Avenue, Englewood Cliffs, New Jersey 07632 and/or Mediconnect.net, Inc., c/o RapiDisclose 10705 South Jordan Gateway, Suite 100, South Jordan, Utah 84095 for the purpose of: possible litigation

6.I understand I have the right to revoke this authorization at any time. I understand that, if I revoke this authorization, I must do so in writing and present my written revocation to the health information management department. I understand the revocation will not apply to information that has already been released in response to this authorization. I understand the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event or condition: not applicable. If I fail to specify an expiration date, event or condition, this authorization will expire in six months.

7.I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand I may inspect or copy the information to be used or disclosed, as provided in CFR 164.524. I understand any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact HIM Director, privacy officer, or other office or individual’s name or contact information.

8.I understand that N.J.A.C. §13:35-6.5(c) and N.J.A.C. §8:43G-15.3 require that physicians and hospitals fulfill medical record requests within thirty (30) days and limits the fees that can be charged for copying said medical records. I hereby authorize Goldsmith Richman & Harz, LLP to file suit against the physician and/or hospital that violates these regulations.





Signature of patient or legal representative


_____________________________ ________


If signed by legal representative,

Signature of witness

Relationship to patient


How to Edit Hipaa Compliant Authorization Form Online for Free

The PDF editor works to make completing forms really easy. It is extremely convenient to modify the Hipaa Compliant Authorization Form document. Consider these actions if you want to achieve this:

Step 1: Hit the orange "Get Form Now" button on the website page.

Step 2: Now you are on the document editing page. You may edit, add content, highlight particular words or phrases, put crosses or checks, and put images.

Complete the following sections to fill in the form:

completing nj hipaa medical release form step 1

Enter the demanded details in Date, and Signature, of, witness box.

Finishing nj hipaa medical release form part 2

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