FREE FILLABLE PDF

Free HIPAA authorization form

Let a chosen person see your medical records. Free fillable PDF.

This PDF is in English.

What's on this form

HIPAA authorization

Let a chosen person see your medical information.

  • Patient and recipient
  • What records may be released
  • Purpose and an end date
  • Revocation notice and signature

Use it this way

Fill, print, sign, store

Type in the PDF fields or print a blank copy. Sign only the way your state requires. Keep the original. Upload a copy to your vault so family can find it.

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Get the form reviewed. Then store it.

Find an estate planning attorney near you. Keep the signed original. Put a copy in your vault.