HIPAA Authorization - Pennsylvania

Pennsylvania · Fillable PDF · Free

This form lets doctors, hospitals and health plans share your medical information with family members or other people you choose. It does not let them make decisions for you; for that, use a Health Care Power of Attorney. This form lets doctors, hospitals and health plans share your medical information with family members or other people you choose.

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Who this form is for

This form lets doctors, hospitals and health plans share your medical information with family members or other people you choose. It does not let them make decisions for you; for that, use a Health Care Power of Attorney.

What you'll need

The original HIPAA Authorization - Pennsylvania packet and its instructions.
The names, dates and supporting records identified in this packet.
Acceptable identification if a notarial act is requested; arrange any required qualified witnesses.

How to complete it

Choose who may release information All of your providers, or only the ones you list.
Name up to three people Each person may receive information separately.
Choose what may be shared Mental health, drug and alcohol, HIV and genetic records are shared only if you initial them.
Set an expiration Write a date or an event. If left blank, it expires two years after signing.
Sign it, and notarize if needed Some insurers and out-of-state providers ask for a notarized authorization.

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These forms are a free convenience, not legal advice. First Choice Mobile Notary & Apostille is not a law firm. Consult an attorney licensed in the relevant state for legal questions.

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