HIM19000 Authorization To Disclose Protected Health Information
Use a HIM19000 Authorization To Disclose Protected Health Information 2019 template to make your document workflow more streamlined.
What this authorization form does
HIM19000 Authorization To Disclose Protected Health Information is a written permission form that lets a patient authorize a named person or organization to receive specified health information. The form identifies the patient, authorized recipient, information to disclose, purpose, expiration or revocation terms, and required signatures. In a U.S. healthcare workflow, the covered entity reviews the authorization before releasing records under HIPAA. With signNow, a provider can upload the form, detect fillable fields, send it to the patient, capture an electronic signature, and retain the completed record with its audit trail.
Who uses this authorization form
Healthcare providers
Healthcare providers use the authorization to document a patient’s permission before releasing specified records to another provider, attorney, insurer, caregiver, or family member. Staff should verify the recipient, scope, purpose, expiration, and signature before disclosure.
Patients and representatives
Patients and authorized representatives use the form to direct disclosure of selected medical records. The completed authorization helps recipients request the exact information permitted without expanding access beyond the patient’s stated scope.
How the authorization workflow works
The signNow workflow follows the form from preparation through signed-record retention, while staff verify each disclosure detail before releasing information.
Upload form: Upload form Detect fields: Detect fields Send securely: Send securely Store evidence: Store evidence
Complete the authorization in signNow
Follow these steps to prepare HIM19000, obtain the patient’s authorization, and preserve evidence of the completed disclosure permission.
Upload form:
Upload the HIM19000 PDF to signNow. Check fields:
Review detected fields and add missing ones. Add details:
Enter the patient and recipient details. Send form:
Send the authorization to the patient. Save evidence:
Download the signed form and audit trail.
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Recommended HIM19000 workflow setup
Configure HIM19000 around verified patient identity, limited disclosure scope, documented consent, and retrievable evidence for every completed authorization.
| Setting | Recommendation |
|---|---|
| Authentication method | Email link with SMS OTP |
| Signature type | Patient electronic signature |
| Audit trail | Enabled for every completed form |
| Document retention | 6 years under HIPAA 45 CFR 164.530(j) |
| Encryption | TLS 1.2/1.3 and AES-256 encryption |
Key features for HIM19000 workflows
signNow connects form preparation, patient signature collection, disclosure controls, and record evidence in one workflow for HIM19000 authorizations.
Field detection
Upload HIM19000 and let signNow detect fillable fields, reducing manual placement work before staff review the patient, recipient, purpose, and expiration information.
Remote signing
Send the authorization by email or signing link so patients can review and sign without an in-person appointment, subject to the organization’s consent policy.
Audit trail
Capture signer activity, timestamps, and document history in an audit trail that can accompany the completed authorization during records review.
HIPAA workflow
Use HIPAA-compliant signNow workflows with a BAA to help protect protected health information during preparation, signing, and storage.
Controlled templates
Reuse a reviewed HIM19000 template while limiting editing rights to authorized staff responsible for disclosure processing.
Mobile access
Access the form on desktop or mobile devices, allowing patients and staff to complete the authorization when an office visit is impractical.
Security for protected health information
HIPAA protection:
Transit encryption:
Storage encryption:
Independent assurance:
Security certification:
Regional compliance:
Find and fill out the correct him19000 authorization to disclose protected health information
airSlate SignNow helps you fill in and sign documents in minutes, error-free. Choose the correct version of the editable PDF form from the list and get started filling it out.
| Versions | Form popularity | Fillable & printable |
|---|---|---|
| *2019 UCHealth HIM19000 [2019-03] 2022 | 4.8 Satisfied (66 Votes) | |
| *2019 UCHealth HIM19000 [2019-03] 2019 | 4.8 Satisfied (156 Votes) |
What the audit trail records
The audit trail provides separate evidence from the form fields, showing how the patient’s authorization was authenticated, completed, sealed, and retrieved.
Authenticate signer:
Timestamp events:
Hash document:
Seal record:
Log actions:
Export trail:
Record retention and audit practices
Preserve the signed authorization, disclosure scope, and supporting audit evidence according to HIPAA retention and internal records policies.
Retain authorization records for six years
Export the audit trail with the form
Restrict access to completed forms
Preserve changes and revocations
Retention schedule for signed authorizations
Keep the completed HIM19000 authorization and its supporting evidence according to the applicable HIPAA documentation rule; unrelated record classes do not control this form.
6 years from creation or date
Not applicable to health records
Not applicable to employment records
Not applicable to brokerage records
Not applicable to safety records
Privacy and disclosure pitfalls
Sending the completed form through unsecured email can expose names, diagnoses, dates of service, or other protected health information. A missing patient signature, date, purpose, recipient, or expiration term can prevent the covered entity from honoring the authorization. Selecting an overly broad record category may disclose more protected health information than the patient intended. Leaving shared templates or completed forms accessible to unauthorized staff can create an avoidable access-control failure.
Managing users and permissions
Health information managers can maintain a controlled HIM19000 template, assign staff permissions, and require authorized senders to collect patient signatures. Shared templates reduce changes to recipient, purpose, expiration, and disclosure fields while preserving an auditable workflow for each completed authorization. Clinic administrators can delegate sending without granting every employee broad document access. signNow user administration, templates, audit trails, and mobile apps help separate preparation, signature collection, review, and retention responsibilities for protected health information workflows.
Troubleshooting authorization workflows
Use these answers to resolve signature, scope, privacy, plan, and retention questions before releasing protected health information.
HIM19000 has no patient signature. How should it be corrected?
A HIPAA authorization includes an unclear recipient. What should staff do?
Does signNow support HIPAA workflows for this authorization?
Which signNow plan includes this document’s audit trail?
Can a patient sign this authorization from a phone?
How long should the completed authorization be retained?
Key performance indicators that demonstrate SignNow's proven track record.
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