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When & Why You Need a HIPAA Authorization Form

February 18, 2021

If you’ve been managing your HIPAA program manually, maybe even using an old HIPAA binder, you probably associate HIPAA with a lot of paperwork. While most of your HIPAA program can now be tackled digitally (and with a time-saving partner, hint hint), there are some papers that are 100% still relevant – like the HIPAA Authorization Form. 

What is a HIPAA Authorization Form, and when do I need one? 

Having a signed HIPAA Authorization Form is one of the many requirements under the Privacy Rule. The authorization form (sometimes called a patient HIPAA consent form), essentially serves as a handy dandy permission slip allowing a practice or business associate to use or disclose protected health information (PHI) in the ways a patient wants their data used. 

Now, just to clear things up, there ARE times you can disclose PHI WITHOUT an authorization form – namely, for regular healthcare payment, treatment, and operations. This means that patients can be treated without an authorization form and that you can share their data as necessary to conduct business without penalties under HIPAA. There are some additional specific scenarios where you don’t need a signed authorization form to share PHI, but most important to note are when you DEFINITELY should have a consent form signed. This includes when PHI is used or disclosed:

  • In any way otherwise not permitted by the HIPAA Privacy Rule 
  • For marketing purposes
  • Related to psychotherapy notes other than for specific healthcare operations 
  • Includes substance abuse and treatment records 
  • For research purposes
  • AND ESPECIALLY prior to the sale of PHI 

Without getting the green light from the patient (in writing) in any of these circumstances, your practice can get into some pretty big trouble. 

What should be included on the HIPAA Authorization Form itself?

If you’re thinking of a lengthy legal document, you’re actually in for some good news – the Authorization Form can be short, sweet, and to the point as long as it covers the following key pieces:   

  • The name of the person(s) or business (aka your practice) authorized to make the requested use or disclosure
  • The name of any third parties to whom the practice may make the requested use or disclosure
  • A description of the specific information that may be used or disclosed 
  • A description of the purpose for the requested use or disclosure 
  • The expiration date or a specific expiration event when the form will expire (such as when they are no longer a patient)
  • And of course, the patient’s name, signature, and date that the form was signed

In addition to the specific elements that must be included within the document, there are also a few statements that should be outlined including:  

  • The patient’s right to revoke the authorization in writing 
  • The practice’s ability to still use their PHI for normal healthcare operations, and that statement that treatment is not conditioned upon the authorization form
  • Any exceptions to the patient’s right to revoke authorization (for example, if the practice has already taken action in reliance on the authorization)

How long does the authorization remain valid?

The Authorization form remains in effect until the listed expiration date or event that was listed when the patient signed the form. We recommend reviewing your authorization forms every few years or so however, to confirm none of the data has changed and anytime an outside event would require a new form (such as a name change, patient who turns 18, or other scenario). The patient also has the ability to change their mind at any time, and can revoke their authorization (in writing) whenever they choose.

Why do I need one?

You don’t have to be an expert on the ins and outs of HIPAA to know that it’s main focus is to protect the privacy and security of patient information. The authorization form helps to do just that – limit patient information to the organizations or individuals designated by the patient to receive their health conditions, insurance information, and any other sensitive data housed within your practice. By getting a form signed from each patient, you’re protecting both the patient and your practice to best disclose information as designated and without any surprises.     

After last year’s enforcement trend centered around patient right of access along with the recent proposal to modify the HIPAA Privacy Rule (with some specific changes related to patient authorization and the Notice of Privacy Practices), giving your practice a head start on meeting important HIPAA standards now is key. If you aren’t using an authorization form, there’s no better time like the present to start implementing a form that fully complies with the Department of Health and Human Services requirements.

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What OSF Healthcare’s Ransomware Fine Teaches Every Practice About SRAs

August 5, 2026 Penelope Schweitzer No comments yet

August 5, 2026 The latest HIPAA fine is another clear reminder that ransomware attacks are, unfortunately, here to stay in the healthcare industry. A settlement involving the OSF Healthcare System was recently announced by the Office for Civil Rights (OCR). As an enterprise healthcare provider in the midwest, the organization serves 174 locations, including 16 hospitals – a prime target for a ransomware attack.    So, what happened?  In April 2021, OSF discovered that they joined the unlucky club of ransomware victims when a malicious actor deployed Nephilim, a ransomware strain made to target larger organizations. Once the ransomware infected OSF systems, the hacker demanded payment or patient Protected Health Information (PHI) would be leaked online. In this attack, sensitive information like financial account information, driver’s license numbers, medical record numbers, and more, were all exposed. Over 53,000 patient records were exposed in this attack.  When ransomware attacks in healthcare have soared 278% in recent years, it’s more of a when then an if your organization doesn’t have the right safeguards in place.  While the breach was discovered in April, OSF healthcare reported the breach to the OCR in October. The OCR took it from there, digging into what precautions (or lack thereof) let this happen.  What did the OCR discover? If you’ve read any of our other fine breakdowns, you already know where this is going: another missing Security Risk Analysis (SRA).  The SRA is a required document every HIPAA-regulated entity (ie: every practice and their Business Associates that handle patient information) needs to complete. The SRA is a thorough review of the physical, technical, and administrative safeguards in place to prevent PHI ending up in the wrong hands. While the OCR didn’t specify exactly how the ransomware got into OSF’s system, a technical safeguard vulnerability was very likely the entry point. A proactive SRA could have flagged that gap before it turned into a major breach. In addition to missing this required documentation, OSF also took too long to report the breach to the OCR and notify affected patients. This is a direct violation of the Breach Notification Rule, which requires organizations to notify patients within 60 days of a discovered breach. Moreover, since the breach impacted more than 500 patients, OSF was also required to report this breach to the OCR within 2 months as well. Time is of the essence in every component of a breach, from securing systems to ensuring affected parties are aware to protect themselves and an over five month delay was unacceptable in the eyes of the OCR.    What was the result?  OSF’s settlement tops the list as the largest fine of the year, coming in at $552,250, plus government monitoring for the next two years.  It’s very important to note that this breach occurred in 2021, meaning that over five years were spent from the initial breach, to investigations, to the public press releases. Also, the average cost of a healthcare breach is over 7 million dollars –  from implementing secure systems, notifying patients, legal fees, and more. The Takeaway While the settlement payment and Corrective Action Plan (CAP) are just the cherries on top, this experience was a tremendous cost of time, money, and resources, highlighting the importance of making sure everything is secure before a situation occurs.  So, when was the last time you looked at your SRA? It’s time to seriously analyze your current compliance posture. Ransomware groups don’t check whether you’re a small dental office or a 16-hospital health system before they attack, they check whether the door was left open. Time and again, OCR’s findings come back to the same root cause: organizations can’t secure what they haven’t even identified as a problem. Looking to review your current compliance standings? Meet with our team of experts for a complimentary educational consultation. 

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June 19, 2026 Penelope Schweitzer No comments yet

June 19, 2026   Quick Guide:  The Office for Civil Rights issued a major fine towards Spencer Gifts benefits plan. This fine reinforces that all HIPAA-regulated entities must have a thorough compliance program.    The Stats You Need to Know 76%: The percentage of large healthcare breaches now caused by hacking/IT incidents. $450,000: Financial settlement of this enforcement. 10,023: The number of individuals were impacted in this breach.  264%: The increase in ransomware-related breaches reported to the OCR since 2018.   When you think about Spencer’s, you likely picture the staple mall store with pop culture novelty gifts, not the latest HIPAA settlement enforcement headline.  Spencer Gifts LLC Flexible Benefits and Welfare Benefit Plans, or their employee benefits plan, reached a settlement with the Office for Civil Rights for $450,000 and a 2 year Corrective Action Plan (CAP).  This fine is a reminder that Covered Entities include all parties that create and utilize patient data, including health care plans. While they might not see patients traditionally, they still are responsible for keeping Protected Health Information (PHI) secure.    What Happened?   In response to employee complaints regarding access to their employee benefits portal, Spencer Gifts Health Plan discovered their systems were infiltrated with ransomware in November 2021. Malicious actors encrypted over 10,000 individuals’ PHI and demanded a ransom. The exposed data included names, phone numbers, social security numbers, and more, putting employees at risk.  The breach was reported in January 2022. After years of investigation, it was settled that the plan failed to meet basic HIPAA Security Rule requirements proactively.    The Compliance Gaps A common misconception is that an organization faces a financial penalty due to a breach. While the breach serves as the catalyst for the investigation, the OCR is looking to see if an organization has a thorough compliance program in place and made a genuine effort to protect patient data.  For instance, the health plan did not complete a Security Risk Analysis (SRA). This required assessment identifies all technical, administrative, and physical safeguards (and vulnerabilities) across your organization. By completing this document, your organization can address concerns before they become an issue. There’s no way to know where risks are unless they are properly reviewed.  Additionally, the plan did not have sufficient policies and procedures, nor trained staff adequately. Without sufficient policies and training, staff are left without the tools to recognize and respond to HIPAA threats before they escalate. As a result, Spencer Gifts now faces $450,000 in penalties and two years of government monitoring to ensure those missing requirements are finally implemented. And that figure doesn’t account for the years of investigation, legal fees, breach notification costs, and operational disruption that preceded the settlement.   The Biggest Takeaway This case isn’t only a lesson for retail organizations’ health plans, but it’s a warning for every HIPAA-regulated entity. The OCR can and will investigate any organization exposed for failing to meet HIPAA requirements, including small medical practices To be prepared before a cyberattack occurs, make sure your organization has: A completed and current Security Risk Analysis. A trained workforce that knows how to handle PHI Accessible policies and procedures staff can actually reference. An up-to-date compliance program.  Ready to strengthen your compliance program? Schedule a free educational consultation with our team today.

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May 4, 2026 Penelope Schweitzer No comments yet

May 4, 2026   Quick Guide:  The Office for Civil Rights (OCR) just issued a massive wake-up call, announcing four simultaneous settlements totaling $1,165,000. The Stats You Need to Know 76%: The percentage of large healthcare breaches now caused by hacking/IT incidents. 427,000+: Total number of patients impacted across these four recent settlements. 264%: The increase in ransomware-related breaches reported to the OCR since 2018. The Office for Civil Rights (OCR) just announced a flurry of investigation settlements. At the root of the four that were announced: ransomware. Ransomware attacks continue to target healthcare facilities. As of last year, the OCR discovered that 76% of large breaches are due to hacking and IT shortcomings. Unfortunately, healthcare information is a goldmine for hackers, exposing sensitive data that can lead to identity theft, financial fraud, and compromised patient care. Breakdown & Lessons Learned Regional Women’s Health Group (Axia) The first settlement was regarding the Regional Women’s Health Group (Axia), an OBGYN network across five states. In this case, the organization submitted a breach report following a cyberattack that exposed over 37,000 patients. The settlement resulted in a $320,000 fine and a 2-year Corrective Action Plan (CAP). The Lesson: The OCR didn’t just fine them for being hacked; they reached a settlement because the healthcare organization failed to conduct a “thorough and accurate” Security Risk Analysis (SRA). If you don’t know where your vulnerabilities are, you can’t patch them. Unfortunately, hackers counted on this negligence and exploited it.  Assured Imaging This was the largest of the four fines, affecting a staggering 244,813 individuals. When a ransomware infection hit their servers, Assured Imaging, a medical imaging enterprise, reported a breach to the OCR. After a long investigation (the initial cyberattack occurred in 2020), and resulted in a $375,000 settlement and a 2-year CAP.  The Lesson: Beyond the initial ransomware attack, it was discovered that Assured had never completed an SRA. Additionally, the organization did not notify patients within 60 days of discovery of the breach. This is a direct violation of the Breach Notification Rule, which aims to allow patients to take control and mitigate risks as quickly as possible.  Consociate Health Consciate Health is the only Business Associate (BA) fine in the four. BAs continue to be under the OCR’s microscope, such as potentially needing to follow stricter requirements when handling patient data. Their breach started with a phishing attack that eventually led to the encryption of systems holding data for over 136,000 people. The BA discovered the ransomware six months after the initial phishing attack. Upon the OCR’s further investigation, the SRA was found to be insufficient. The organization paid a $225,000 settlement and entered into a 2-year CAP.  The Lesson: Human error (phishing) is the most common entry point for ransomware. Constant employee training is just as important as a strong firewall. Additionally, just because a BA doesn’t directly work with patients doesn’t mean it isn’t their responsibility to keep patient data secure.  SG Health Plan Even employee benefit plans are regulated under the Health Insurance Portability and Accountability Act (HIPAA). SG Health Plan, associated with a Connecticut energy provider, reported that the data of 9,316 members were exposed following a ransomware attack. It was discovered that the organization did not complete an extensive SRA. The benefit plan entered a settlement with the OCR for $245,000 and a 2-year CAP.  The Lesson: This settlement highlights that HIPAA applies to corporate health plans just as much as it does to traditional healthcare providers. Additionally, every organization that handles Protected Health Information (PHI) must complete an SRA.  The Bottom Line The OCR isn’t fining practices for ransomware attacks, but for being ill-prepared.  However, it is easier said than done to ensure your organization is secure in protecting patient data and complying with HIPAA.  Proactively implementing the HIPAA Security Rule is your opportunity to mitigate the impacts of a cyberattack. Waiting until the ransom note appears on your screen is a million-dollar mistake. Want to see what you might be missing?  Run a 5-Minute HIPAA Gap Assessment and protect your practice today! 

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