Ovs Claim Application And Instructions (Page 7 of 7) in pdf

OCA Official Form No.: 960

*HIPAA*

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

XXX-XX-__ __ __ __

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:

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 only if I 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.

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

prohibited from redisclosing 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 (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for

protecting my rights.

3. 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.

4. 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.

5. Information 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.

6. 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 (b).

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

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

NYS OFFICE OF VICTIM SERVICES – AE SMITH BLDG., 80 S. SWAN ST., ALBANY, NY 12210-8002

9(a). Specific information to be released:

 Medical Record from (insert date) ___________________ to (insert 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: __________________________________

Include: (Indicate by Initialing)

__________________________________

________ Alcohol/Drug Treatment

________ Mental Health Information

Authorization to Discuss Health Information

________ HIV-Related Information

(b)  By initialing here ____________ I authorize ________________________________________________________________

Initials

Name of individual health care provider

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

NEW YORK STATE OFFICE OF VICTIM SERVICES

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

(Attorney/Firm Name or Governmental Agency Name)

10. Reason for release of information:

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

At request of the individual for purposes of establishing

This authorization will expire upon the termination of the

eligibility for New York State Office of Victim Services

individual’s eligibility for Office of Victim Services benefits.

benefits.

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

13. Authority to sign on behalf of patient:

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

of the form.