Authorization For Release Of Health Information Pursuant To Hipaa

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NEW YORK STATE DEPARTMENT OF HEALTH

Authorization for Release of Health Information Pursuant to HIPAA

State Disability Review Unit

Patient Name:

Date of Birth:

Social Security Number (Last four digits):

Address:

Client ID Number(CIN):

Disability ID Number(DIN):

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:

1. This authorization may include disclosure of information relating to Alcohol and Drug Abuse, Mental Health Treatment, except psychotherapy notes, and

Confidential HIV Related Information, unless I check the appropriate box(es) in section 9(c). Otherwise, in the event the health information described

below, in section 9(a), includes any of these types of information, and I initial the line on the box in section 9(b), I specifically authorize release of such

information to the person(s) or entity indicated in Section 8.

2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from

re-disclosing such information without my authorization unless permitted 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 HIV-related information without authorization. If I experience discrimination because of the release or

disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (888) 392-3644 or TDD/TTY (718) 741-8300

3. I have the right to revoke this authorization at any time by writing to the health care provider listed below in Section 7. I understand that I may revoke this

authorization except to the extent that action has already been taken based on this authorization. If not previously revoked, this authorization will expire

upon completion of this determination/review or one year from the date this form is signed, whichever comes first.

4. I understand that signing this authorization is voluntary. I understand that the State Disability Review Unit requires the completion of this form in order to gather

health information necessary for a disability determination. I understand that without this authorization, my eligibility for Medicaid benefits may be affected.

5. Information disclosed under this authorization might be re-disclosed by the Department of Health (except as noted under item 2), and this re-disclosure

may no longer be protected by federal or state law.

6. This authorization does not authorize you to discuss my health information or medical care with anyone other than the government agency specified in

Section 9(b).

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

8. Name and address of person(s) or agency to whom this information is to be sent:

State Disability Review Unit OCP-826, State of New York, Department of Health, Albany, NY 12237

9(a). Specific information to be released:

Medical records from ____________________ (date) to ____________________ (date).

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.

Other: ____________________________________________________________________________________________________________

9(b). Authorization to discuss Health Information:

By initialing here ________ I authorize ___________________________________________________________________________________

(NAME OF INDIVIDUAL/HEALTH CARE PROVIDER)

to discuss my health information with the State Disability Review Unit.

9(c). I do not consent to the disclosure of (Check all boxes that apply):

Alcohol/Drug Treatment

Mental Health Information

HIV-Related Information

10. Reason for release of information:

At request of individual

Other:______________________________________

Disability Determination and Review

11. Purpose of the Use/Disclosure:

12. If not the patient, name of the person signing this form (print):

13. Type of authority to sign on behalf of the patient:

All sections on this form have been completed and my questions about this form have been answered.

I authorize the facility/person noted on this page to release health information of the person named on this page to the New York State Department of Health State

Disability Review Unit.

SIGNATURE OF THE PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW

DATE

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