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NEW YORK CITY DEPARTMENT OF

HEALTH AND MENTAL HYGIENE

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

Patient Name

Date of Birth

Patient Identification 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 Privacy Rule of the Health Insurance Portability and Accountability 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/AIDS* RELATED INFORMATION only if I place my initials on the appropriate line in Item 7. 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 7, I

specifically authorize release of such information to the New York City Department of Health and Mental Hygiene DOHMH .

2. If I am authorizing the release of HIV/AIDS-related, alcohol or drug treatment, or mental health treatment information, DOHMH 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 the people who may receive or use my HIV/AIDS-related information without authorization. If I

experience discrimination because of the release or disclosure of HIV/AIDS-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 providers 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 DOHMH (except as noted above in Item 2), and this redisclosure

may no longer be protected by federal or state law.

6. I AUTHORIZE ALL MY HEALTH CARE PROVIDERS TO RELEASE THIS INFORMATION TO, AND DISCUSS THIS INFORMATION WITH, NEW

YORK CITY DEPARTMENT OF HEALTH AND MENTAL HYGIENE.

7. Specific information to be released and discussed:

Entire Medical Record (written and oral) including patient histories, office notes (except psychotherapy notes), test results,

radiology studies, films, referrals, consults, billing records, insurance records, and records send to you by other health care

providers.

□

If this box is checked, release and discuss only my Medical Record from (insert date)______________to (insert date)____________

Include: (Indicate by Initialing)

□

_______Alcohol/Drug Treatment Information

Other: ________________________

_______Mental Health Information

________________________

_______HIV/AIDS-Related Information

REASON FOR RELEASE OF INFORMATION: THIS INFORMATION IS

THIS AUTHORIZATION WILL EXPIRE ONE (1) YEAR FROM THE DATE THIS

RELEASED AT REQUEST OF THE PATIENT OR REPRESENTATIVE

AUTHORIZATION IS SIGNED BY THE PATIENT OR REPRESENTATIVE UNLESS

UNLESS OTHERWISE SPECIFIED HERE:

OTHERWISE SPECIFIED HERE:

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

11.

THE PERSON SIGNING THIS FORM IS AUTHORIZED BY LAW TO SIGN

ON BEHALF OF THE PATIENT AS THE PARENT OR LEGAL GUARDIAN OF THE

PATIENT, OR AS SPECIFIED HERE:

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

_________________________

___________________________________________________________________________________

SIGNATURE OF PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW

DATE

*Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify

so eo e as havi g HIV sy pto s or i fectio a d i for atio regardi g a perso ’s co tacts.

Rev 1/2017

Request For Section 504 Accommodations 2017-2018 - New York City Department Of Health And Mental Hygiene Page 2

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