Templates
HIPAA waiver form

HIPAA waiver form

A HIPAA waiver form allows patients to grant permission for the release of their health information under specific circumstances.

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HIPAA waiver form

A HIPAA waiver form allows patients to grant permission for the release of their health information under specific circumstances.

Use this template with Lumiform

The Lumiform application helps frontline teams uphold internal standards effortlessly.
  • Customize this template or build your own
  • Fill out templates via mobile app
  • Assign and track corrective actions
  • Get reports and analyse your data
Prices start from ░░░ per month
Book a demo
Learn more
or Download template as PDF

This HIPAA waiver form template addresses the critical challenge healthcare providers face when needing to disclose protected health information without patient authorization. Created for healthcare compliance officers and administrators, it includes all necessary components required by federal regulations: documentation of minimal privacy risk, plans for protecting identifiers, and written assurances against improper disclosure.

You can customize this template for various scenarios including research purposes, emergency situations, or when individual authorization is impracticable. Rather than spending hours crafting a compliant document from scratch, this template ensures you have a ready-to-use solution that meets all regulatory requirements.

Related categories

Preview of the template
Patient Consent
I hereby authorize the release of my protected health information as described below.
Information to be Disclosed
Medical records
Billing records
Other (please specify)
Purpose of Disclosure
Coordination of care
Personal use
Other (please specify)

Frequently asked questions

What is the difference between a HIPAA waiver and a HIPAA authorization form?

A HIPAA waiver allows disclosure of PHI without patient permission in specific circumstances, typically requiring IRB approval. In contrast, patients sign HIPAA authorization forms to voluntarily permit sharing of their information with specific parties. Waivers operate as exceptions to normal rules, while patients provide explicit consent through authorizations.

What are the major elements that must be present in a valid HIPAA waiver form?

A valid HIPAA waiver must document minimal privacy risks, include identifier protection plans, outline identifier destruction methods, provide written assurances preventing improper disclosure, and justify why researchers cannot conduct the study without the waiver or PHI access.

Who has the authority to approve a HIPAA waiver request?

Only an Institutional Review Board (IRB) or a Privacy Board has the authority to approve a HIPAA waiver request. Documentation must include the approval date, confirmation of satisfied waiver criteria, description of accessible PHI, and the IRB chair’s or designated member’s signature.

How long is a HIPAA waiver form valid once approved?

The validity period of a HIPAA waiver should be specified in the approval documentation. For research purposes, it typically covers the duration of the study. For emergency situations, HHS waivers are usually limited to 72 hours after a hospital implements its disaster protocol or until the emergency declaration ends.

This template, developed by Lumiform employees, serves as a starting point for businesses using the Lumiform platform and is intended as a hypothetical example only. It does not replace professional advice. Companies should consult qualified professionals to assess the suitability and legality of using this template in their specific workplace or jurisdiction. Lumiform is not liable for any errors or omissions in this template or for any actions taken based on its content.