HIPAA Release Form

The Health Insurance Portability and Accountability Act, also known as HIPAA, was created in 1996 by the US Congress to protect the privacy of your health information. The act prohibits your health care providers from releasing your health care information unless you have provided your health care provider with a HIPAA release form.

Unless you have provided a signed release form, your health care providers are prohibited from discussing any aspect of your medical information with anyone who is not directly involved in your care.

Let's look at a quick example from the side of the health care provider:

In this example, we will assume your elderly mother has been hospitalized. You rush to the hospital and ask the Emergency Department nurse how your mother is doing. You are directed to contact your mother's physician. Your mother's physician informs you that, unless your mother provides him with a medical release form, he/she is not permitted to provide you with information related to her hospitalization stay.

Now let's look at an example from the side of the insurance provider:

Let's continue with the example from above. Your mother has been hospitalized. The bills start pouring in. You notice that the insurance company has been denying the claims with a footnote indicating the policy has been terminated. You contact the insurance company to determine what has happened. You are informed that, they cannot provide you with any information unless your mother provides them with signed authorization (her release) naming you as her agent.

Personally, I have provided a release form to each of my physicians and insurance carrier requesting they release all information to my husband on my behalf. To have full access, consider that this release include both medical and financial information so that you can talk to health care providers and billing personnel.

If you wish to consider doing the same for yourself or your friends/family, please feel free to print this HIPAA Release Form.

If you need one that has less detail, this basic HIPAA release form should do the trick.

Please note, you must have Adobe® Reader® on your computer to view these forms. If you do not have this software, and would like a free copy of it, please click

now.

HOME

Continue to Hospital Checklist Form