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Medical Authorization Form
A medical authorization form is used to give another person, a hospital, or an insurance company medical authorization for a patient’s legal rights. This free online medical authorization form has benefits like:- Protecting patients’ privacy
- Sharing the medical information of patients easily
- Providing legal consent and authority
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About this medical authorization form template
A medical authorization form is a method used to obtain legal permission to access, share, or release a patient’s medical information or to authorize medical treatments if the patient is unable to give consent. You can access these essential questions and features below, and give consent for free:
Form questions will collect information about:
- Patient’s full name and contact details
- Date of birth and identification number
- Authorized person or organization details
- Type of medical information to be shared
- Purpose of authorization (treatment, billing, insurance, etc.)
- Expiration date of authorization
- Emergency contact information
- Patient’s or guardian’s signature and date
Features that we meticulously included for your needs, such as:
- Contact fields to easily collect key patient details, such as name, email, phone number, and address.
- Date & time fields to set the authorization’s start and end dates clearly using a calendar tool.
- Legal fields to add consent checkboxes and signature fields to provide valid authorization.
- File upload fields allow patients to upload required documents, such as ID copies, medical records, or scans.
- Multiple-choice fields to let patients specify which medical information can be shared, such as lab results, X-rays, or prescriptions.
- Logo & cover to add the healthcare provider’s branding and cover image to create an official form.
What can I ask in a medical authorization form?
The questions to ask in a medical authorization form can vary depending on the patient, their medical condition, the procedures, and the operations. However, the questions below will be enough to create a draft to get started:
- What is the patient’s full name?
- What is the patient’s date of birth?
- What is the patient’s phone number and email address?
- Who is authorized to access or receive the patient’s medical information?
- What type of medical information may be shared (e.g., lab results, X-rays, prescriptions)?
- For what purpose will the medical information be used (treatment, billing, insurance, etc.)?
- When should this authorization start, and when should it expire?
- Do you want to place any restrictions on the information to be shared?
- Who should be contacted in case of an emergency?
- Please provide your signature and today’s date to confirm consent.
How can I track responses?
Once you have completed your form, you’ll have a dedicated results page. There, you will have access to AI insights, Statistics, and Responses. Here is what you can do with them:
AI Insights
AI Insights is an innovative feature that enables you to analyze form responses with AI. You can get general trends, related charts, key points, and suggestions, as well as ask more questions about the analysis.
Statistics
Statistics offers a number of valuable information for you, as a form owner. Once you are in Statistics, you will be able to see data about your form, respondents, and answers. Additionally, you will have access to data on device types, platforms, locations, scores, and more.
Responses
In the Responses section, you have two viewing options: List and Grid view. After selecting and viewing a submission, you can print it, add a note, or send it to the trash. You can view the percentages and get a general idea of the submissions on the statistics page. Also, you can download your data as .xls or .csv files.
Frequently asked questions (FAQs)
Can I add my own logo to this template for free?
Yes, it is! You are free to add your logo in any convenient place for free. You can use the Logo field to upload your logo. Additionally, you can enhance your branding by adding a Cover field, which allows you to place a horizontal image.
Which field(s) are vital in my medical authorization form?
The most critical fields in a medical authorization form are contact fields, date & time fields, and legal fields, all of which are essential to ensure clarity in the most critical sections of the form.
Can I share this template in multiple languages?
是的! If your audience speaks different languages, you can add multiple languages and let people choose their preferred language when they open up your form. Please note that this feature is available only on Pro and Premium plans.
Use this medical authorization form template
Follow the three quick steps below to start collecting patient consent and healthcare information safely.
2. Customize as you like
Add or remove questions through forms.app's drag-and-drop interface and match your brand style.
3. Share it on all channels
Embed it on your website in 6 different ways or share your form across all social media channels.
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Smooth intake process for everyone
Create your medical authorization form with powerful features and make the intake process simple and clear for everyone.
Contact fields
Collect fundamental patient data such as name, email, phone number, and address easily.
Date & time fields
Easily record the validity period, when the authorization starts, and ends with a calendar.
Legal fields
Add a consent and signature field so parties can sign the form and provide valid consent.
File upload fields
Upload the necessary documents, such as ID cards, scans, and medical records, in any format.
Multiple-choice fields
To specify which types of information can be shared (lab results, X-rays, prescriptions, etc.).
Conditional logic
Show relevant questions based on the answers to have more extensive details, or just hide irrelevant ones.