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HIPAA Consent & Authorization

2 pages•11 fields•HIPAA-ready
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Patient Name
Date of Birth
Phone Number
Email Address
HIPAA Privacy Notice & Consent
I agree to the terms above
Sign here
Acknowledgment of Patient Rights
I agree to the terms above
Sign here
Authorization for PHI Disclosure
Communication Preferences
Select...
Restrictions on Communications
Date Signed
Patient Signature
Sign here
Submit
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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.

What's included

  • Patient demographics with date of birth, phone, and email
  • HIPAA consent agreement with e-signature
  • Consent for treatment, payment, and operations
  • Patient rights acknowledgment
  • PHI disclosure authorization
  • Communication preference selection
  • Communication restriction details
  • Annual re-authorization support

Who uses this template

  • All healthcare practices subject to HIPAA
  • New patient onboarding across all specialties
  • Annual HIPAA re-authorization
  • Telehealth and remote patient onboarding

All form fields

11 fields across 2 pages. Customize any field after signing up.

Patient NameText
Date of BirthDate
Phone NumberPhone
Email AddressEmail
HIPAA Privacy Notice & ConsentConsent Agreement
Acknowledgment of Patient RightsConsent Agreement
Authorization for PHI DisclosureCheckbox
Communication PreferencesDropdown
Restrictions on CommunicationsLong Text
Date SignedDate
Patient SignatureE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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