Phi Authorization Form for the United States

Phi Authorization Form Template for United States

A PHI Authorization Form is a legally binding document required under U.S. federal law (HIPAA) that gives healthcare providers and other covered entities permission to use or disclose protected health information to specified recipients for specific purposes. This document must comply with both federal HIPAA requirements and any additional state-specific privacy laws, which may impose stricter standards for certain types of health information.

Your data doesn't train Genie's AI

You keep IP ownership of your information

Generate a Bespoke Document

1. Select your governing law:

2. Enter your key requirements:

3. Create your document to edit, review or download

Download a Standard Template

Get our United States-compliant Phi Authorization Form

4.6 / 5

4.8 / 5

Alternatively: Run an advanced review of an existing
Phi Authorization Form

Let Genie AI's market-leading legal AI identify missing terms, unusual language, compliance issues and more - in just seconds.

Upload your Doc

What is a Phi Authorization Form?

The PHI Authorization Form is a crucial document required by U.S. federal law whenever protected health information needs to be shared with third parties. This form ensures compliance with HIPAA regulations and state privacy laws while protecting patient rights. The document specifies what information can be shared, with whom, for what purpose, and for how long. It includes mandatory elements such as a description of the information to be disclosed, the purpose of disclosure, expiration date, and the patient's right to revoke the authorization. The form must be written in plain language and signed by the patient or their legal representative.

What sections should be included in a Phi Authorization Form?

1. Patient Information: Basic identifying information about the patient including name, date of birth, address, and contact details

2. Authorization Statement: Clear statement indicating the patient's permission to share Protected Health Information (PHI)

3. Information to be Disclosed: Specific description of what health information can be shared, including type and date range of records

4. Purpose of Disclosure: Explicit reason why the information is being shared or released

5. Recipient Information: Details of individuals or entities authorized to receive the information

6. Expiration: Specific date or event when the authorization expires

7. Rights Statement: Description of patient's rights including right to revoke authorization and right to refuse to sign

8. Signature Block: Area for patient/representative signature, date, and witness signature if required

What sections are optional to include in a Phi Authorization Form?

1. Specific Authorizations: Special permissions required for sensitive information such as HIV status, mental health records, or substance abuse treatment

2. Representative Authorization: Section for legal representative details and proof of authority when someone other than the patient is authorizing disclosure

What schedules should be included in a Phi Authorization Form?

1. State-Specific Addendum: Additional provisions and requirements specific to the applicable state law

2. Detailed Records List: Comprehensive itemized list of specific medical records to be disclosed

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Cost

Free to use

Relevant legal definitions

Clauses

Authorization Grant
Information Description
Purpose of Disclosure
Duration and Expiration
Revocation Rights
Re-disclosure Notice
Patient Rights
Minimum Necessary Disclosure
Confidentiality
Special Categories Authorization
Electronic Disclosure
Information Accuracy
Recipient Authorization
Security Measures
State Law Compliance
Signature Requirements
Personal Representative Authority
Records Access

Relevant Industries

Healthcare
Insurance
Research
Education

Relevant Teams

Medical Records
Compliance
Legal
Privacy
Administration

Relevant Roles

Privacy Officer
Medical Records Manager
Healthcare Administrator
Compliance Officer
Medical Office Manager

Find the exact document you need

No matches found.

Military Medical Record Request Form

U.S. legal document for requesting military medical records in compliance with federal privacy laws.

How Cambridge United Uses Genie AI to Speed Up Player Signings and Slash Legal Costs

Generate a Bespoke Document

Download a Standard Template

What is a Phi Authorization Form?

What sections should be included in a Phi Authorization Form?

What sections are optional to include in a Phi Authorization Form?

What schedules should be included in a Phi Authorization Form?

Authors

Alex Denne

Jurisdiction

Publisher

Document Type

Sector

Cost

Find the exact document you need

Military Medical Record Request Form

Employment Background Check Release Form

Phi Consent Form

Phi Authorization Form

Dr Work Release Form

Police Vehicle Release Form

Authorization For Release Of Protected Health Information Phi

Form For Requesting Medical Records

Share Medical Information Form

Release Of Records Request Form

Release Of Information Statement

Release Form From Police Department

Printable Work Release Form

Military Dependent Medical Records Request Form

Medical Records Pick Up Form

Letter For Medical Records Request

Generic Dental Records Release Form

Employee Photo Consent Form Gdpr

Dental Release Of Information Form

CT Medical Records Release Form

Consent For Use And Disclosure Of Health Information Form

Authorization To Release Rental History

Authorization To Release Credit Information Form

Authorization To Disclose Medical Information Form

Authorization Release Form For Background Check

Athletic Medical Release Form

Minor Medical Treatment Authorization Form

Medical Consent Form For Temporary Guardian

Authorization For Release

Written Authorization To Release Information

Workers Comp Medical Release Form

Work Release Form Hospital

Veterinary Medical Release Form

Universal Medical Release Form

Service Release Form

Revocation Of Release Of Information Form

Release Form For Video Recording

Records Request Form Medical

Public Adjuster Release Form

Physician Medical Release Form

Genie’s Security Promise

Your documents are private:

Your documents are protected:

Organizational security:

Templates

Contract Templates

Letter Templates

Policy Templates

Industries

Legal Services

Manufacturing

Construction

Solutions

Use Cases

Company Types

Comparisons

Business Categories

Teams

Information

Generate Legal Docs Free