HIPAA Authorization for Release of Protected Health Information (Dallas Bar Association)
Texas · TexasLawHelp.org
This form lets a person give permission for their private health information to be shared with specific people or groups. It directs healthcare providers to release the information to the named representatives.
The court describes it as: Use form to authorize release of protected health information to chosen entities or individuals.
Where this fits in a case
General & infoInformation / general use — not tied to one step of a case
This form is used when a person wants to authorize the release of their protected medical information to designated people or groups.
Either party may file.
Common questions
- Who should fill out this form?
- The form requires the person whose health information is being discussed to fill it out and sign it.
- What does this form allow to be shared?
- It allows the sharing of all protected medical information, which includes records about medical history, diagnosis, treatment, and billing.
- What happens if I sign this form?
- By signing, the person agrees that the shared health information might no longer be protected by privacy laws.
Revision history
No changes recorded since we started tracking this form on October 9, 2026.
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