About this template
This HIPAA Authorization Google Form template is designed for healthcare providers, clinics, and mental health professionals who need to obtain formal patient consent for the disclosure of protected health information (PHI). It provides a clear, professional way to document exactly what information is being shared, who is authorized to receive it, and the specific purpose of the disclosure.
By using this template, you ensure that your practice maintains a structured and transparent record of patient permissions. The form covers essential details including the patient's identity, the scope of the medical records to be released, the timeframe for the authorization, and the necessary signatures to validate the request. It is an essential tool for maintaining administrative compliance and ensuring that your patients' privacy preferences are respected and documented accurately.
Key features
- Clear sections for defining the scope and purpose of disclosure.
- Includes fields for patient and guardian signatures.
- Easily shareable via link, email, or embedded on your website.
- Automatically organizes responses in a linked Google Sheet.
- Fully customizable to match your clinic's branding.
Use cases
- Transferring medical records between healthcare providers.
- Granting family members access to health information.
- Authorizing insurance companies to review treatment plans.
- Releasing mental health notes for legal or disability claims.
What this form collects
- Patient Full Name (Short answer)Enter the full legal name of the patient.
- Date of Birth (Date)Format: MM/DD/YYYY
- Person or Entity Authorized to Disclose Information (Short answer)Name the doctor, hospital, or organization authorized to release your records.
- Purpose of Disclosure (Paragraph)State the reason for this request (e.g., personal use, insurance claim, transfer of care).
- Information to be Disclosed (Checkboxes)Select the types of medical information you authorize for release.
- Authorization Expiration Date (Date)When should this authorization expire? If no date is provided, it will expire in 1 year.
- Patient Signature (Short answer)Please type your full name as a digital signature to confirm your authorization.
- Parent or Guardian Full Name (Short answer)Complete only if the patient is a minor or unable to sign.
- Relationship to Patient (Short answer)Specify your relationship to the patient (e.g., Parent, Legal Guardian).
FAQ
Is this form template compliant with HIPAA?
This template provides the necessary fields to capture the information required for a HIPAA-compliant authorization. However, please ensure your overall Google Workspace environment is configured for HIPAA compliance before collecting sensitive health data.
Can I add custom fields for specific medical records?
Yes. You can easily add, remove, or modify fields within the Google Form editor to include specific medical record types or additional legal disclosures relevant to your practice.
How do I handle signatures on this form?
While Google Forms does not have a native 'draw-to-sign' field, you can use the 'Short Answer' field for a typed signature or include a file upload link where patients can submit a signed PDF if your specific workflow requires a handwritten signature.
Where is the data stored?
All responses are stored securely in your Google Drive, specifically within the Google Form and its associated Google Sheet, allowing you to manage access permissions according to your organization's security policies.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.