West Park Medical Group Individual Records Release Authorization (Page 2 of 3) in pdf

□ The following HIV-related information (which is any information indicating that you have had

an HIV-related test, or have HIV infection, HIV-related illness or AIDS, or any information

which could indicate that you have been potentially exposed to HIV):

What is the purpose of the use or disclosure? The appropriate boxes should be checked

below, and the descriptions should be in sufficient detail so that our office staff can understand

the purpose(s) for which health information may be used or disclosed.

□ The health information you have indicated to the person(s) you have indicated

□ Other purpose:

When will this authorization expire? The date or event that will trigger the expiration of this

authorization is:

SPECIFIC UNDERSTANDINGS

By signing this authorization form, you authorize the use or disclosure of your protected health

information as described above. You should note that when your protected health information is

disclosed to people or entities that are not required to abide by federal or state medical privacy

laws, those people entities may re-disclose your information to others and use your information

without being subject to penalties under those laws.

If you are authorizing the release of HIV-related information, you should be aware that the

recipient(s) is prohibited from redisclosing any HIV-related information without our

authorization unless permitted to do so under federal or state law. You also have a right to

request a list of people who may receive or use your HIV-related information without

authorization. If you experience discrimination because of the release or disclosure of HIV-

related information, you 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 your rights.

You have the right to refuse to sign this authorization. Your health care, the payment for your

health care, and your health care benefits will not be affected if you do not sign this form.

You also have a right to receive a copy of this form after you have signed it.

If you sign this authorization, you will have the right to revoke it at any time, except to the extent

that our practice has taken action based upon your authorization. To revoke this authorization,

West Park Medical Group Individual Records Release Authorization Page 2