Form Rs 6410 - Application For 605a Accidental Disability Page 3
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3AUTHORIZATION FOR RELEASE
OF HEALTH INFORMATION
Office of the New York State Comptroller
New York State and Local Retirement System
PURSUANT TO HIPAA
Employees’ Retirement System
Police and Fire Retirement System
RS 6429
110 State Street, Albany, New York 12244-0001
(Rev. 5/15)
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 8(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 8(a), I specifically authorize release of such information to the person(s) indicated in Item 7.
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 (1-888-392-3644) or (212-961-8650). This agency is responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider(s) 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. 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.
5. 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 8(b).
6. Name and address of health care provider(s) or entity(ies) to release this information:
7. Name and address of person(s) or category of person to whom this information will be sent:
New York State and Local Retirement System, Mail Drop 7-1, 110 State Street, Albany NY 12244
8. (a) Specific information to be released:
… Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies,
films, referrals, consults, 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
Authorization to Discuss Health Information
(b) By initialing here___________
I authorize ___________________________________________________________________
Initials
Name of individual health care provider
to discuss my health information with my attorney or governmental agency, listed here:
New York State and Local Retirement System
(Attorney/Firm Name or Government Agency Name)
9. Reason for release of information:
10. This authorization will expire at the completion of the disability
retirement application process.
… At the request of individual
… Other:
11. If not the patient, name of person signing form:
12. 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.
_______________________________________________________________
_____________________________________________
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
someone as having HIV symptoms or infection and information regarding a person’s contacts.
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