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Free Sample HIPAA Patient Release Form

Updated on April 20, 2010

Sample HIPAA disclosure form for Doctors Offices, Chiropractors Offices, and Dentist Offices

Sample HIPAA Privacy Disclosure –

(VERY IMPORTANT: This is not a legal document. This document is just a sample, and should not be reviewed or acknowledged as legal advice. I am not an Attorney! Additionally, this sample HIPAA Privacy Disclosure Form for Patients to sign has several office specific portions that you would need to complete in a similar document. Remember, to verify the accuracy of this document, you'll want to consult an attorney. Additionally, though most of the important terminology is included in this form, you'll need to do some work to format it in a way that makes it easy to read for your clients. Again, "be safe, call a lawyer!" we have several attorney recommendations that can help you create this form to the right!)

(Your sample HIPAA disclosure form should include a notice of privacy at the beginning of the document. A sample of this type of disclosure is listed below.)



(You will also want to include some form of privacy pledge on your HIPAA release form. This should reassure your patients that your company is committed to their privacy, and that you will not take advantage of your rights to their health information)

Our Privacy Pledge
We want you to understand that we respect your privacy. Other than the necessary uses and disclosures we described above, we will not sell your health information or provide any of your health information to any outside marketing company.

(Below you'll find a sample of the uses and disclosures on a sample HIPAA release form. It is important that this portion of the document gives your patients specific examples of reasons that you may need to use or disclose their health care information. If you are a chiropractor or dentist, you may want to substitute the word "doctor" for your specific profession.)

Uses and Disclosures
Below you will find examples of how we may have to use or disclose your health care information:
1. Your doctor or a staff member may have to disclose your health information (up to and including all of your clinical records) to another health care provider or a hospital if it is necessary to refer you to them for diagnosis, assessment, or treatment of your health condition.
2. It may be necessary for our insurance and/or billing staff to disclose your examination and treatment records and your billing records to another party, such as an insurance carrier, your employer, a family member, other relative or close personal friend, who is involved in our care or to facilitate the payment related to your care.
3. It may be necessary for the doctor and members of the staff to use your health information, examination, and treatment records and your billing records for quality control purposes or for other administrative purposes to efficiently and effectively run our practice.
4. Your doctor and members of the practice staff may need to use your information (ex. name, address, phone number, and your clinical records) to contact you to provide appointment reminders, information about treatment alternatives, or other health related information that may be of interest to you. 164.520(b)(1)(iii)(A). If you are not at home to receive an appointment reminder, a message will be left on your answering machine.

As our patient, you possess the right to refuse to give us the authority to contact you regarding the above-mentioned circumstances. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.

You may inspect or copy the information that we use to contact you.

(This section of the free sample HIPAA disclosure form gives your patients information about how you may need to use their medical information, and that for these specific reasons, you will not need to obtain consent. You're probably familiar with these reasons, include any additional examples you my incur in your practice. Remember, this form should not be used as legal advice. For a more accurate version, contact an attorney that specializes in forming documents like the HIPAA disclosure.)

Permitted uses and disclosures without your consent or authorization

Under federal law, we are also permitted or required to use or disclose your health information without your consent or authorization in these following circumstances:

1. If we are providing services to you based on the orders of another health care provider.
2. If we provide health care services to you in an emergency or disaster relief situation.
3. If we are required by law to treat you and we are unable to obtain your consent after attempting to do so.
4. If we are provide health care services to you as a result of a Workers’ Compensation injury.
5. If you are/ were a member of the armed forces, we are required by military command authorities to release your health information.
6. If we provide health care services to you as an inmate.
7. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.
Other than the circumstances described in the above examples, any other use or disclosure of your health information will only be made with your written consent.

(This portion of the sample HIPAA form reminds your clients that they are not signing a permanent release to all of their medical information, and gives them specific information on how they will need to revoke the authorization to release medical records that they gave you. On most forms I've seen, the practice requires that patients revoke the authorization in writing. I'm sure we all understand why.)

Your right to revoke your authorization

You may revoke (take away) your privacy release authorization from us at any time; however, your revocation must be in writing. You can call for information about revoking your authorization during normal business hours, or send your request to the address listed below. There are two circumstances under which we will not be able to honor you revocation request.
1. If we have already released your health information before we received your request to revoke your authorization. 164.508(b)(5)(i).
2. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims. If you wish to revoke your authorization, please write to us at:


(This section of the free sample HIPAA release form informs patients that they have the right to modify the rights they give you to disclose health information. If a patient would rather amend the section of the contract you develop (again, this form is just a sample, and is not considered legal advice... call an attorney!) to refuse you the right to leave a message regarding non-life threatening medical information... they can. This section is to inform the patient of that right.)

Your right to limit uses or disclosures
If there are health care providers, hospitals, employers, insurers, or other individuals or organizations to whom you do not want us to disclose your health information, please let us know, in writing, what individuals or organizations to whom you do not want us to disclose your health care information. We are not required to agree to your restrictions. However, if we agree with your restrictions, the restriction is binding on us. If we do not agree to your restrictions, you may drop your request or you are free to seek care form another health care provider.

Your right to receive confidential communication regarding your health information
We normally provide information about your health to you in person at the time you receive chiropractic services from us. We may also mail you information regarding your health or about the status of your account. We will do our best to accommodate any reasonable request if you would like to receive information in a different form. To help us respond to your needs, please make any request in writing.

(This section of the free sample HIPAA form just informs the patient of their right to review their own health information, and lets them know how they should go about obtaining this information. Some forms also include the office address in this section to help clients with this process.)

Your right to inspect and copy your health information
You have the right to inspect and /or copy your health information for seven years from the date the record was created or as long as the information remains in our files. We require your request to inspect and / or copy your health information be in writing.

(This section of the free sample HIPAA privacy disclosure form gives the patient the legal time frame in which they must request to amend health information. Usually, this amount of time is 7 years, but you'll want to contact an attorney to be sure. It also gives patients information about obtaining health information recorded before the inception of the HIPPA law. REMEMBER: this is just a free sample HIPAA form, not a legal document or legal advice.)

Your right to amend your health information

You have the right to request that we amend your health information for seven years from the date the record was created or as long as the information remains in our files. We require your request to amend your records to be in writing and for you to give us a reason to support the change you are requesting us to make.

Your right to receive an accounting of the disclosures we have made of your records
You have the right to request that we give you and accounting if the disclosures we have made of your health information for the last six years before the date of your request. The accounting will include all disclosures except:
• Those disclosures required for your treatment, to obtain payment for your services, or to run our practice.
• Those disclosures made to you.
• Those disclosures necessary to maintain a directory of the individuals in our facility or to individuals involved in your care.
• Those disclosures made for national security or intelligence purposes.
• Those disclosures made to correctional officers or law enforcement officers.
• Those disclosures that were made prior to the effective date of the HIPPA privacy law.

(This section of the free HIPAA privacy release form is to inform your patients about your legal requirements to protect their health information, and that the patients rights may change as laws change etc. Did I mention that this is not a legal document, and should not be considered legal advice. Have you called an attorney yet?)

Our Duties
We are required by law to maintain the privacy of your health information. We are also required to provide you with this notice of our legal duties and our privacy practices with respect to your health information.

We must abide by the terms of this notice while it is in effect. However, we reserve the right to change the terms of our privacy notices. If we make a change in our privacy terms the change will apply for all of our health information in our files.

Information that we use or disclose may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules.

(This section of the sample HIPAA form (AGAIN, FOR A FORMAL HIPAA FORM THAT YOU CAN USE, CALL AN ATTORNEY THAT SPECIALIZES IN CONSTRUCTING LEGAL DOCUMENTS. SEVERAL ARE LISTED ABOVE AND AT THE TOP RIGHT!) provides your information to the client. Many clients will request a copy of this form, so it helps them to have all of your contact information provided. It also lets them know how to file a formal complaint if they believe you have not respected their privacy rights as according to this agreement and the HIPAA. ).

For more information or to report a problem

If you have questions and would like additional information, you may contact our practice’s Chief Privacy Officer at (XXX) XXX-XXXX, or in writing to the Chief Privacy Officer, (INCLUDE FULL ADDRESS HERE). If you believe your privacy rights have been violated, you can either file a complaint with this office, or with the office for Civil Rights, U.S. Department of Health and Human Services (OCR). There will be no retaliation for filing a complaint with either our practice or the OCR. The address for the OCR regional office for North Carolina is as follows:

Office for Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3870
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909

(And, as most documents do, this sample HIPAA privacy disclosure form ends with a place for a signature. This, on your form (which you should contact an attorney to write), is where you would have the patient sign to authorize you to release their health information as needed. This section may also require them to list their current insurance provider, and any other parties that may require access to the patients health information. A lot of people will personalize this section by using the doctors name, and by listing specific insurance policies that apply.)

I authorize you to use or disclose my health information in the manner described above. I am also acknowledging that I understand I may receive a paper copy with this authorization at my request. This notice is effective as of (Date). This authorization will expire seven years after the date in which you last received services form us.

ASSIGNMENT OF BENEFITS: I voluntarily direct ____________________________________ Insurance company (or Attorney at Law) to pay (COMPANY NAME OR DOCTOR NAME HERE) directly for charges for professional services rendered to me. THIS IS A DIRECT ASSIGNMENT OF BENEFITS UNDER THIS POLICY. I agree that I am responsible for any balance over and above insurance/attorney payment for these services. If my current insurance policy prohibits direct payment to (COMPANY NAME OR DOCTOR NAME HERE), I instruct you to make the check to me and mail it as follows: (COMPANY MAILING ADDRESS HERE). I authorize (COMPANY NAME OR DOCTOR NAME HERE), to initiate a complaint to the Insurance Commissioner for any reason on my behalf. I understand and agree that if collection efforts are necessary to obtain payment on this account, I will be responsible for all costs of such collection efforts, including reasonable attorney fees. I understand that any unpaid balance will accrue monthly interest at 1.5-% after 30 days of delinquency, unless prior payment arrangements are made.

Driver’s License Number: ____________________________ State: _____

CONSENT TO TREAT: I voluntarily authorize (COMPANY/DOCTOR NAME HERE) and whomever (DOCTOR NAME HERE) designates as assistants or associates to administer examinations and care as deemed necessary for my condition.

Emergency Contact Name: __________________________________________________ Phone: ___________________________

AUTHORIZATION TO RELEASE RECORDS: I voluntarily authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in my case.

_________________________________________________________ ____________________________
Patient Name Printed Date

_______________________________________________________________ ________________________________
Patient Signature Witness Signature

HIPAA Privacy Disclosure

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      3 years ago

      Great article. Thanks for the info, it’s easy to understand. BTW, if anyone needs to fill out a HIPAA Patient Authorization Release Form, I found a blank form here:

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