HIPAA Authorization Form Generator
Build a HIPAA Authorization for Use or Disclosure of Protected Health Information form that includes every core element required by the Privacy Rule at 45 CFR 164.508.
Open the generator → Runs in your browser. Data leaves only if you deliberately send a problem report from the interactive tool.
Example
- Patient name
- Jane Doe
- Plan / covered entity
- Acme Health Plan
- Information to be released
- medical records 2024-2025
- Recipient
- New Provider Internal Medicine
- Purpose of disclosure
- continuity of care
- Expiration
- 2027-05-15
Result: Click "Build printable authorization" for a 45 CFR 164.508 letter listing patient, plan, info, recipient, purpose, and expiration.
The tool opens with these values already filled in. Replace them with your own.
What you enter
Patient name; the plan or covered entity; what is being released; the recipient; the purpose; and an expiration.
What this is
Build a HIPAA Authorization for Use or Disclosure of Protected Health Information form that includes every core element required by the Privacy Rule at 45 CFR 164.508: the specific information to be used or disclosed, the recipient, the purpose, the patient's signature and date, the expiration date or event, the right to revoke in writing, the statement that PHI may be re-disclosed once released, and the conditioning-of-treatment disclaimer. Sophie Well fills the form in from short prompts and outputs a printable document ready to sign.
When to use it
Use this when a patient needs to authorize a one-time disclosure of records that falls outside the routine TPO (treatment, payment, operations) framework - releasing records to an attorney, an employer, a life-insurance underwriter, or a third-party caregiver, or for a research study that requires explicit consent. The 164.508 authorization is distinct from a HIPAA Right of Access request: this is the patient authorizing disclosure to a third party; the Right of Access request (also generated by Sophie Well) is the patient requesting their own records be sent somewhere. Both are valid; they serve different legal purposes.
How this is calculated
HIPAA Privacy Rule, 45 CFR 164.508. Required-element template; covered entities may add their own elements.
A reference and educational tool. Not medical, legal, or financial advice, and not a substitute for clinician judgment.