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Medical Treatment Obtained Pursuant To This Authorization Form

Use a Medical Treatment Obtained Pursuant To This Authorization template to make your document workflow more streamlined.

What this medical authorization form does

The Medical Treatment Obtained Pursuant To This Authorization Form gives a designated person or organization permission to obtain specified medical treatment or related records for the individual named in the authorization. The signer identifies the patient, authorized recipient, requested treatment or information, purpose, and applicable limits. A healthcare provider may rely on the completed form only within its stated scope and subject to applicable federal and state privacy rules. If protected health information is involved, HIPAA requirements and the provider’s procedures still apply. Keep the signed form and audit trail together.

Organizations using this authorization

The form serves healthcare workflows where a patient’s permission, a defined recipient, and controlled treatment information access must be documented.

  • Solo medical practices can use a reusable authorization template to capture a patient’s designated recipient, treatment scope, purpose, signature, and date without coordinating paper exchanges.
  • Healthcare groups can route authorizations through role-based staff, apply HIPAA controls, and retain signed records with audit trails for release, care coordination, or approved administrative purposes.
  • Enterprise provider networks can connect signNow with systems such as Salesforce, NetSuite, Google Drive, or Microsoft 365 while central administrators manage permissions and retention policies.

These tasks are executed by both individual contributors and centralized administrators depending on organizational policy and required controls.

Complete the authorization form online

Use signNow to prepare the medical authorization, capture the required signature, and preserve the completed record.

  • Upload form:

     Upload the authorization form and confirm every patient, provider, and records field.

  • Check fields:

     Review detected fields and add missing signature, date, and authorization details.

  • Add signer:

     Enter the authorized recipient’s email address and select the required signing order.

  • Store records:

     Send the completed authorization, then download the signed copy and audit trail.

How the authorization audit trail works

The audit trail records technical evidence around this authorization, helping show who accessed, completed, and signed the document.

01

Authenticate signer:

 Confirm signer identity through email verification or configured authentication.
02

Capture timestamps:

 Record the exact date and time for every signing action.
03

Hash document:

 Create a document hash as the authorization changes.
04

Seal record:

 Preserve a tamper-evident completed record and certificate.
05

Track actions:

 Log recipient access, field completion, and signature events.
06

Retrieve evidence:

 Export the signed authorization and audit trail for retention.
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Recommended authorization workflow setup

Use controlled authentication, a complete audit trail, and retention aligned with the records handled under this authorization.

SettingRecommendation
Authentication methodEmail verification with SMS OTP
Signature typeTyped or drawn electronic signature
Audit trailCapture timestamps, IP address, and signer actions
Document retention6 years for HIPAA records (45 CFR 164.530(j))
EncryptionTLS 1.2 or 1.3 in transit and AES-256 at rest

Connect authorization records to business systems

Connect signNow with healthcare, storage, and enterprise systems to route this medical authorization, preserve the signed record, and reduce duplicate entry across approved workflows.

Salesforce
Procore
Zapier
Microsoft Teams
Hub spot
Box
Microsoft

Platform requirements for signing

Open the Medical Treatment Obtained Pursuant To This Authorization Form in Chrome, Firefox, Safari, or Edge on Windows or macOS. signNow mobile apps support iOS and Android, allowing authorized users to review and sign from a supported mobile device. Use a secure TLS connection when handling patient information.

  • Browsers Chrome, Firefox, Safari, and Edge
  • Desktop systems Windows and macOS desktops
  • Mobile access iOS and Android mobile apps

Organizations handling protected health information should manage devices, user permissions, and signNow access centrally. Confirm that the workflow includes the required BAA, appropriate authentication, audit-trail access, and retention controls. API or SSO deployment may require a plan with the relevant capability, such as Site License or Enterprise features.

Security for medical authorizations

HIPAA protection:

 HIPAA compliant with BAA

Data in transit:

 TLS 1.2 and 1.3 encryption

Stored data:

 AES-256 encryption at rest

Security assurance:

 SOC 2 Type II certified

Security management:

 ISO 27001 certified

Regulated records:

 21 CFR Part 11 compliant

Privacy and disclosure pitfalls

  • Including unrelated treatment details can disclose more protected health information than the stated authorization purpose requires.
  • Leaving the authorized recipient, purpose, or expiration information unclear can delay provider review or narrow the authorization’s usable scope.
  • Sending the completed form to an unverified email address can expose patient information outside the intended recipient’s control.
  • Failing to retain the signed form and audit trail can make it difficult to demonstrate consent, scope, and signer attribution later.

Retention periods for authorization records

Choose the retention period based on the record’s actual purpose, the presence of PHI, and applicable federal and state requirements.

01

Six years for HIPAA records

HIPAA requires covered entities to retain required policies, procedures, and related documentation for six years.
02

Three years for tax records

IRC §6501(a) generally keeps tax records three years from filing when the authorization supports tax-related medical documentation.
03

Six years for major understatement

IRC §6501(a) allows six years when income was understated by 25 percent or more.
04

Indefinite for fraud cases

IRC §6501(a) provides indefinite retention where fraud occurred or no return was filed.
05

Longer period under state law

State healthcare-record rules may require longer retention than federal rules; verify the applicable state requirement.

Best practices for retaining authorizations

Retention should preserve the authorization’s scope, signer evidence, and privacy controls throughout the record’s required life.

Keep the signed form with evidence

Retain the signed authorization, its audit trail, and any certificate of completion together. For HIPAA-related documentation, apply the six-year period in 45 CFR §164.530(j), unless applicable state law or another controlling requirement requires longer retention.

Export the audit trail promptly

Export the audit trail after completion and record the export date, document identifier, and responsible administrator. Preserve the file in a restricted repository so staff can demonstrate signer identity, timestamps, access events, and the authorization’s final content.

Restrict access to PHI

Limit access to personnel whose duties require the authorization. Apply role-based permissions, protect downloaded copies, and avoid storing patient information in unapproved email, local folders, or consumer storage locations outside the organization’s records policy.

Match disclosure to stated purpose

Review the authorization’s scope before release and confirm the recipient matches the named person or organization. Do not use a completed form for a different purpose without obtaining a new authorization when required by HIPAA or state law.
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Troubleshooting authorization workflows

These answers address field detection, signer access, HIPAA handling, plan features, legal validity, and retrieval of completed authorization records.

On signNow’s Business plan, upload the Medical Treatment Obtained Pursuant To This Authorization Form as a PDF and use fields for the patient, authorized recipient, scope, purpose, signature, and date. If auto-detection misses a field, add it manually before sending.

The Business plan includes legally binding eSignatures and audit trails. For patient-facing records, signNow lists HIPAA compliance as available with a BAA requirement. Confirm that the organization has executed the BAA and configured access controls before processing PHI.

A signer can often open the request without a signNow account, depending on the sender’s workflow. If identity assurance is required, use SMS OTP or an Enterprise authentication option, then verify the signer’s identity before accepting the authorization.

Business Premium is the signNow plan that includes bulk send. Use it only when the same authorization template is sent to multiple recipients with appropriate individualized patient and scope information; never reuse another patient’s completed data.

Electronic signatures generally receive legal recognition under ESIGN, 15 U.S.C. ch. 96, and UETA, but the authorization must show intent, consent, attribution, and record reproducibility. State healthcare rules, provider policy, and HIPAA obligations may impose additional requirements.

If a completed form cannot be located, search the signNow document history and export the audit trail with the signed PDF. Retain both together, restrict access to authorized personnel, and apply the organization’s HIPAA retention policy where applicable.

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