AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[This form has been approved by the New York State Department of Health]

Patient Name

Date of Birth

Social Security Number

Patient Address

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:

This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only ifl place my initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
If I am authorizing the release of IflV-related, alcohol or drug treatment, or mental health treatment infonnation, the recipient is prohibited from redisclosing such infonnation without my authorization unless pennitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my IflV-related infonnation without authorization. If I experience discrimination because of the release or disclosure of IflV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting my rights.
I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
Infonnation disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.
THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 Cb).

7. Name and address of health provider or entity to release this information:

8. Name and address ofperson(s) or category of person to whom this information will be sent:

9(a). Specific information to be released:

Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.

Medical Record (insert date below)

Other

From

If other

Include: (Indicate by Initialing)

Alcohol/Drug Treatment

Mental Health Information

HIV-Related Information

Authorization to Discuss Health Information

By initialing here

I authorize

to discuss my health information with my attorney, or a governmental agency, listed here:

10. Reason for release of information:

At request of individual

Other

If other

11. Date or event on which this authorization will expire:

12. If not the patient, name of person signing form:

13. Authority to sign on behalfofpatient:

All items on this form have been completed and my questions about this fonn have been answered. In addition, I have been provided a copy of the form.

Signature of patient or representative authori:zed by law.

Date

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person's contacts.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

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We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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