HIPAA Authorization for Third-Party Billing
Patient Name
Date of Birth
Recipient of Information
Name of Third-Party (e.g., Billing Company)
Address
Information to Be Disclosed
Describe the health information to be disclosed
Purpose of Disclosure
Purpose of Disclosure (e.g., Billing, Payment, Claims)
Authorization Expiration
This authorization will expire on (date or event):
Your Rights
You may refuse to sign this authorization.
You may revoke this authorization in writing at any time.
Your health care and payment for health care will not be affected if you do not sign this form.
Signature
Signature of Patient or Representative
Date
If signed by Representative, Relationship to Patient