OCA Official Form 960 - Feb 2004

The HIPAA Authorization Form is a legal document used to authorize the release of an individual's protected health information (PHI) as governed by the Health Insurance Portability and Accountability Act (HIPAA). The form requires the individual to provide their personal information, the information to be released, and the purpose of the release.

Individuals who wish to authorize the release of their protected health information.

The completed form should be submitted to the healthcare provider or organization that will be releasing the protected health information.