Juniper Vale Medical Center
Privacy & Health Information Office
450 Juniper Way, Cedarwick, EX 01001 · (555) 010-0190 · privacy@junipervale.example
Sample authorization layout
Sample reference DEMO-NOT-FILED-HIPAA-00831
Educational example only

Authorization to Use or Disclose Protected Health Information

Educational layout referencing HIPAA authorization concepts · 45 CFR §164.508
Fictional sample — not authorized
FICTIONAL GENERATED EXAMPLE — NOT A MEDICAL PROVIDER, PATIENT RECORD, OR AUTHORIZATION — DO NOT SUBMIT OR RELY ON THIS SAMPLE
1
Patient (Individual Authorizing Disclosure)
Sample patient name
Sample Patient
Sample date of birth
SAMPLE-DOB
Sample member / account #
SAMPLE-ACCOUNT-20917
Sample mailing address
100 Sample Lane, Cedarwick, EX 01001
Sample phone
(555) 010-0241
2
Sample Provider & RecipientThis fictional layout illustrates fields that may appear in a health-information authorization.
ASample provider
Provider / practice
Juniper Vale Medical Center
Address
450 Juniper Way, Cedarwick, EX 01001
Phone / fax
(555) 010-0190 / fax (555) 010-0191
BSample recipient
Recipient / organization
Pinehaven Assurance Services — Sample Review
Address
PO Box SAMPLE-4820, Pinehaven, EX 01002
Phone / fax
(555) 010-0466 / fax (555) 010-0470
3
Information Authorized for Release
Sample educational selection of relevant record categories only; this display does not authorize a disclosure or describe an actual patient.
Laboratory resultsBlood panels, urinalysis, screenings
Vital signsBlood pressure, height, weight, BMI
Diagnoses & problem listActive and resolved conditions
Medication listCurrent prescriptions and dosages
Office visit / progress notesExcluded for this purpose
Imaging & radiologyOnly if separately requested
Other (sample):SAMPLE-ANNUAL-SUMMARY
Records dated SAMPLE-STARTthroughSAMPLE-END or all available dates
4
Purpose & Expiration
Purpose of this disclosure
Sample underwriting-review scenario Continuing care Personal use Legal
Sample stated reason
SAMPLE-REVIEW-SCENARIO — DEMO-NOT-FILED-77104
Sample expiration field
SAMPLE-EXPIRATION
Illustrative field placement only; this sample does not establish an authorization period or any rights.
5
Educational Notes — Do Not Sign or Submit
  1. Educational context. A real authorization must be prepared and reviewed by the applicable provider, patient, and privacy professionals.
  2. No provider relationship. Juniper Vale Medical Center and Pinehaven Assurance Services are fictional names used only to demonstrate layout.
  3. No disclosure. This sample does not release, request, describe, or authorize any protected health information.
  4. No reliance. Do not submit, sign, copy into a record, or rely on this sample for legal, medical, insurance, or privacy purposes.
FICTIONAL GENERATED EXAMPLE — NOT A MEDICAL PROVIDER, PATIENT RECORD, OR AUTHORIZATION — DO NOT SUBMIT OR RELY ON THIS SAMPLE.
6
Sample Signature Fields — Not Valid
SAMPLE-SIGNATURE
Sample signature field
DEMO-NOT-FILED-DATE
Sample date field
SAMPLE-PATIENT
Sample printed name
SAMPLE-DOB
Sample date-of-birth field
Illustrative representative section only; this sample cannot be signed or used for any purpose.
Signature of personal representative
Relationship / legal authority
Date
FICTIONAL GENERATED EXAMPLE — NOT A MEDICAL PROVIDER, PATIENT RECORD, OR AUTHORIZATION — DO NOT SUBMIT OR RELY ON THIS SAMPLE Juniper Vale Medical Center · DEMO-NOT-FILED-HIPAA-00831 · Sample 1 of 1