Authorization For Disclosure Of Health Information Page 2
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4HIPAA Compliant Authorization for Release of
New York State Department of Health
Medical Information and Confidential HIV* Related Information
This form authorizes release of medical information including HIV-related information. You may choose to release just your non-HIV
medical information, just your HIV-related information, or both. Your information may be protected from disclosure by federal privacy
law and state law. Confidential HIV-related information is any information indicating that a person has had an HIV-related test, or has
HIV infection, HIV-related illness or AIDS, or any information that could indicate a person has been potentially exposed to HIV.
Under New York State Law HIV-related information can only be given to people you allow to have it by signing a written release. This
information may also be released to the following: health providers caring for you or your exposed child; health officials when required
by law; insurers to permit payment; persons involved in foster care or adoption; official correctional, probation and parole staff;
emergency or health care staff who are accidentally exposed to your blood, or by special court order. Under State law, anyone who
illegally discloses HIV-related information may be punished by a fine of up to $5,000 and a jail term of up to one year. However, some
re-disclosures of medical and/or HIV-related information are not protected under federal law. For more information about HIV
confidentiality, call the New York State Department of Health HIV Confidentiality Hotline at 1-800-962-5065; for information regarding
federal privacy protection, call the Office for Civil Rights at 1-800-368-1019.
By checking the boxes below and signing this form, medical information and/or HIV-related information can be given to the people listed
on page two (or additional sheets if necessary) of the form, for the reason(s) listed. Upon your request, the facility or person disclosing
your medical information must provide you with a copy of this form.
I consent to disclosure of (please check all that apply):
My HIV-related information
Both (non-HIV medical and HIV-related information)
My non-HIV medical information **
Information in the box below must be completed.
Name and address of facility/person disclosing HIV-related and/or medical information:
________________________________________________________________________________________________
________________________________________________________________________________________________
Name of person whose information will be released: __________________________________________________________
Name and address of person signing this form (if other than above):
______________________________________________________________________________________________
______________________________________________________________________________________________
Relationship to person whose information will be released:___________________________________________________
______________________________________________________________________________________________
Describe information to be released:______________________________________________________________________
Reason for release of information: _______________________________________________________________________
Time Period During Which Release of Information is Authorized From: _____________________ To: __________________
Disclosures cannot be revoked, once made. Additional exceptions to the right to revoke consent, if any:
________________________________________________________________________________________________
________________________________________________________________________________________________
Description of the consequences, if any, of failing to consent to disclosure upon treatment, payment, enrollment or eligibility for benefits
(Note: Federal privacy regulations may restrict some consequences):
________________________________________________________________________________________________
________________________________________________________________________________________________
All facilities/persons listed on pages 2, 3 (and 4 if used) of this form may share information among and between themselves for the
purpose of providing medical care and services. Please sign below to authorize.
Signature _________________________________________________________________ Date _________________
*Human Immunodeficiency Virus that causes AIDS
** If releasing only non-HIV medical information, you may use this form or another HIPAA-compliant general medical release form.
Please Complete Information on Page 3.
DOH-2557 (8/05) p 1 of 3
Form #PRIV-02-F01
orig – 10/31/03
reviewed 03/06, 04/08, 02/10
Page 2 of 4
Revised 03/11
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