Client Rights & Forms
HIPAA Authorization Form
Last Updated · June 16, 2026
A HIPAA Authorization is required when we are asked to use or disclose PHI for purposes other than treatment, payment, or health care operations, for example, sharing records with an attorney or for a non-clinical research purpose.
Key Elements
- A specific description of the information.
- Who is authorized to disclose and who may receive it.
- The purpose of the disclosure.
- An expiration date or event.
- Your signature and date.
- You may revoke the authorization in writing at any time.
This document is provided as a draft for informational purposes and is pending final review by qualified healthcare counsel prior to publication to ensure compliance with applicable federal, Florida, HIPAA, telehealth, wellness, and healthcare regulations.