HIPAA Consent & Authorization

The HIPAA Consent & Authorization form is a legal requirement for all healthcare practices subject to HIPAA regulations. This template provides patients with the Notice of Privacy Practices acknowledgment, consent for treatment, authorization for use and disclosure of protected health information (PHI), and communication preference selection.

The form is written in plain, patient-friendly language while maintaining legal compliance with HIPAA Privacy Rule requirements (45 CFR 164.520). It covers how the practice uses PHI for treatment, payment, and healthcare operations; the patient's rights regarding their health information; and the practice's obligations to protect PHI.

Communication preferences allow patients to specify how they want to be contacted (phone, email, text, mail) and any restrictions on communication (e.g., do not leave voicemail, contact only at specific number). The e-signature capture creates a legally binding acknowledgment with timestamp, eliminating the need for paper consent forms. This template should be completed by every new patient and updated annually.