Authorization To Release Health Information Pursuant To Hipaa - Buffalo Medical Group
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1BUFFALO MEDICAL GROUP 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:
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 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 of 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 re-disclosed 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, GOVERNMENTAL AGENCY OR FAMILY MEMBER
SPECIFIED IN ITEM 9(B).
7. Name and address of health provider or entity to release this information:
Buffalo Medical Group, Release of Information Department, 295 Essjay Road, Williamsville, NY 14221 Fax#: 716-630-1251
8. Name and address of person(s) or category of person to whom this information will be sent:
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
__________ HIV-Related Information
(b). By initialing here _______________, I authorize ____________________________________________________________________
Initials
Name of individual health care provider
to discuss my health information with my attorney, governmental agency or family member, (include relationship to patient) listed here:
___________________________________________________________________________________________________________
Specific information to be released/discussed:
All Medical information - For alcohol/drug, mental health or HIV information,, the patient must initial the applicable boxes in Section 9(a).
Medical information limited to:____________________________________________________________________________________
10. Reason for release of information:
11. Date or event on which this authorization will expire:
At request of individual
Other:
12. If not the patient, name of person signing form:
13. Authorization 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.
_______________________________________________________
Date: ___________________________________
Signature of patient or representative authorized by law
*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 contacts.
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