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Patient Advocates 101

An Example Of A HIPAA Authorization Letter

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A HIPAA authorization letter doesn't need to be any more than the following.  As you will see, it is addressed to a specific doctor. It could just as easily be addressed "To Whom It May Be Concerned"

Date

(name and address of doctor)  

Dear Dr. _____________:

Please accept this note as authorization for you to speak directly with _________________ about all aspects of my medical condition, including but not limited to my diagnosis, prognosis, and treatment. (If HIV is part of your diagnosis, use the following wording instead: Please accept this note as authorization for you to speak directly with _________________ about all aspects of my medical condition, including but not limited to my diagnosis, prognosis, and treatment, including information relating to HIV/AIDS.)

This authorization will remain in effect until such time as I deliver to you a written document rescinding it.

Thank you for your consideration.

Very truly yours,


(Print your name and address)


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