This template is used by an employer-sponsored group health plan to obtain the consent of an individual to authorize the plan's use or disclosure of the individual's protected health information (PHI), as may be required under the Health Insurance Portability and Accountability Act (HIPAA). The plan representative must complete this template before furnishing it to the individual for signature, provide a signed copy to the individual, and maintain a record of the authorization in accordance with 45 C.F.R. ยง 164.508(b)(6). This template is drafted for a group health plan, but can be modified for use by other types of HIPAA covered entities, such as a health service provider. The template contains drafting notes and an optional clause. HIPAA strictly limits on how, and for what purposes, covered entities (including many group health plans) can use or disclose PHI. PHI refers generally to health information collected, created, or handled by a covered entity that can be linked to an ...