Patient authorization forms

October 7, 2005

I'm about to open a family practice. Can you outline the elements of a HIPAA patient authorization form?

Q: I'm about to open a family practice. Can you outline the elements of a HIPAA patient authorization form?

A: Forms used to authorize record releases and other protected medical information must contain the following elements: (1) a description of the information to be released; (2) names of the people authorized to release it; (3) names of the recipients; (4) reasons for the disclosure (or, if your patient herself has initiated it, the phrase "at the request of the individual"); (5) an expiration date or terminating event (at the end of a research study, for example); (6) your patient's signature (or that of her personal representative, if so authorized); (7) the date the form was signed; (8) a statement that makes clear your patient's right to revoke her authorization at any time, and steps to accomplish this; (9) a statement noting that the information may be subject to redisclosure by the recipient, and thus no longer protected; and (10) depending upon the situation, a statement that makes clear that any treatment, payment, or benefits your patient receives aren't contingent on her signing the authorization.

Additionally, the authorization must be written in plain language and a patient copy provided, if she wasn't the one initiating the authorization.