Disclaimer
BuiltSIGN templates are provided for convenience, are not legal advice, and should be reviewed by a licensed attorney in the relevant state.
Healthcare and consent
HIPAA Authorization
Authorization drafted around the core elements in 45 CFR 164.508(c).
The legal text of this template is still in English. It needs a human translation by someone qualified in that language and jurisdiction. BuiltSIGN does not machine-translate template bodies.
Preview
Needs legal review
Built from 45 CFR 164.508(c) core elements and required statements. Psychotherapy-note authorizations and other conditions in that section still need a compliance review.
Authorization
The patient authorizes {{discloser}} to disclose this information: {{information}} to the recipient, for this purpose: {{purpose}}. This authorization expires on {{expiration}}. The patient may revoke it in writing except to the extent the discloser has already acted on it. Treat…
Entire agreement
This document and any addenda the parties sign are the entire agreement on this subject and replace earlier discussions about that subject. A change is binding only in a writing signed by the parties who must sign it. If one provision is held unenforceable, the rest stays in effe…
Questions
What is the HIPAA Authorization template?
Authorization drafted around the core elements in 45 CFR 164.508(c). It is a Healthcare and consent template in the BuiltSIGN gallery.
Who signs this template?
The template includes fields for Patient, Recipient.
Is this legal advice?
BuiltSIGN templates are provided for convenience, are not legal advice, and should be reviewed by a licensed attorney in the relevant state.
Is the template text translated?
No. The legal text stays in English until a person qualified in that language and jurisdiction translates it. BuiltSIGN does not machine-translate template bodies.
BuiltSIGN templates are provided for convenience, are not legal advice, and should be reviewed by a licensed attorney in the relevant state.