Date of Birth
Social Security Number
Employee’s School or Work Location, Address (including Room №), City/State/Zip, Telephone and Email
Employee’s Home Address, City/State/Zip, Telephone and Email
I, or my authorized representative, request that health information about 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:
This authorization includes disclosure of information relating to A
except psychotherapy notes, and C
. I understand that, due to the special nature of this
authorization in relation to incidents of blood-borne pathogen exposure, the usual separate authorizations for HIV-related, alcohol or
drug treatment, or mental health treatment information do not apply, and I make all such authorizations by my signature below. In the
event the health information described below includes any of these types of information, I specifically authorize release of such infor-
mation to the person(s) indicated in Item 8.
The recipient of HIV-related, alcohol or drug treatment, or mental health treatment information 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. I may contact the N.Y.S. Division of Human Rights at
(212) 480-2943 or the N.Y.C. Commission of Human Rights at (212) 306-7450. These agencies are responsible to protect my rights.
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.
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.
Information disclosed under this authorization might be re-disclosed by the recipient (except as noted above in Item 2), and this
re-disclosure may no longer be protected by federal or state law.
HIS 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
Name and address of health provider to release this information: New York City Health and Hospitals Corporation (“HHC”),
125 Worth Street, New York NY 10013, on behalf of one of its hospital units providing medical service to the undersigned.
Name and address of person(s) to whom this information will be sent: Board of Education of the City School District of the
City of New York (d/b/a New York City Department of Education), 65 Court Street, Room 706, Brooklyn, NY 11201-4954
(includes Office of the Chancellor, Division of Human Resources, Office of Occupational Safety & Health, Office of Legal Serv-
ices, Office of Labor Relations, Division of School Facilities (for custodial staff only), and employee’s immediate supervisors).
9.1. Specific information to be released: Entire Medical Record maintained by HHC pertaining to my treatment, counseling, etc., for
exposure to blood-borne pathogens including, but not limited to, patient histories, office notes (except psychotherapy notes), test
results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to HHC by other health
care providers. This includes: Alcohol/Drug Treatment, Mental Health Information and HIV-Related Information.
9.2. By initialing here __________, I authorize the New York City Health and Hospitals Corporation to discuss my health infor-
mation with my attorney and/or a governmental agency listed here:
(Attorney/Firm Name and/or Governmental Agency Name)
10. Reason for information release: My request to enable my em-
11. Date or event on which this authorization will expire: My
ployer to administer my treatment benefits.
separation from employment or my written revocation.
13. Authority to sign on patient’s behalf:
12. If not the patient, name of person signing this form:
All items on this form are completed and my questions about this form have been answered. I have been provided a copy of this form.
Signature of patient or representative authorized by law.
Human Immunodeficiency Virus 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’s contacts.