HIPAA Consent Form
A HIPAA consent form records who may receive a patient's health information, what may be disclosed, for what purpose, and until when. All four have to be specific, or the authorisation isn't valid.
For clinics, practices and healthcare providers.
An authorisation without limits isn't an authorisation
The requirement that trips people up is specificity. "I consent to sharing my information" fails on every count - it names no recipient, no category of information, no purpose and no end date.
So this template asks for each of those as separate fields: who, what, why, and an expiry date. It also records the patient's right to revoke, because an authorisation that doesn't tell someone how to withdraw it is defective on its face.
A record you can actually rely on
Consent that was given verbally, or on a paper form in a drawer, is consent you cannot produce when it matters. What you need is the wording they agreed to, the answers they gave, and the date - all in one place.
This template collects exactly that, and every submission is stored with its own timestamp.
Paperwork before the appointment, in the patient's own time
Forms filled in at reception are rushed, incomplete and hand-written. The same questions sent with the appointment reminder come back typed, complete and read at home - and you get the first ten minutes of the appointment back.
They also arrive before you need them, so a flagged medication or a mobility need changes the plan in advance rather than in the room.
Nothing shared, nothing tracked
The page carries no analytics, no third-party scripts and no cookie banner - there's nothing to consent to except what you're asking. For a form about consent, that matters.
Edit it like a document, publish like a link
Add questions, remove questions, change the order and the wording, set your accent colour. When you save, the form is live at its own address - share it by link, QR code or a button on your site, and read the answers in your dashboard.
What this template asks
- Patient's full name
- Date of birth
- Medical record number, if known
- Address
- Name each person or organisation who may receive your information
- Which information may be disclosed?
- Do you also authorise these, if present in your record?
- Anything you want specifically excluded?
- Why is this being shared?
- This authorisation expires on
- I understand I can withdraw this at any time
- I am signing this voluntarily
- I would like a copy of this authorisation
- If you're signing on the patient's behalf, your name and authority
More Healthcare forms
Questions
Is this form HIPAA compliant?
The *form* is a starting point that collects the required elements - it is not legal advice, and compliance depends on your practice, your business associate agreements and your safeguards. Have your privacy officer or counsel review it before use.
Is ava42 a HIPAA business associate?
We don't currently sign BAAs, so don't use this to store protected health information if your compliance programme requires one. Many practices use it for the authorisation record and keep PHI in their clinical system.
Is this legal advice?
No. The wording is a practical starting point, not a legal document - have your own adviser check anything you rely on, especially where health, minors or money are involved.
Is a tick box a valid signature?
In many places a clear, dated, affirmative action is accepted, but it depends on your jurisdiction and what you're doing. If you need a drawn signature, print the response and sign it, or take the form as the pre-appointment record.
Can I keep a copy for the person who filled it in?
Yes - they see a confirmation on screen, and you can turn on an email so a copy of each submission lands in your inbox for your records.
Can I use this for patient information?
Responses are stored in your account, never shared and never used for advertising, and pages are served over encrypted connections. You remain the controller of that data: ask only what you need, say what you keep, and confirm your obligations (HIPAA, UK GDPR or local equivalent) before collecting health information on a web form.
Publish your hipaa consent form today
Start from this template and change anything you like. Free to begin.