Authorization For Disclosure Of Health Information (Page 3 of 4) in pdf

HIPAA Compliant Authorization for Release of

New York State Department of Health

Medical Information and Confidential HIV* Related Information

Complete information for each facility/person to be given general medical information and/or HIV-related information.

Attach additional sheets as necessary. It is recommended that blank lines be crossed out prior to signing.

Name and address of facility/person to be given general medical and/or HIV-related information:

____________________________________________________________________________________________________

Reason for release, if other than stated on page 2:

____________________________________________________________________________________________________

If information to be disclosed to this facility/person is limited, please specify:

____________________________________________________________________________________________________

Name and address of facility/person to be given general medical and/or HIV-related information:

____________________________________________________________________________________________________

Reason for release, if other than stated on page 2:

____________________________________________________________________________________________________

If information to be disclosed to this facility/person is limited, please specify:

____________________________________________________________________________________________________

The law protects you from HIV related discrimination in housing, employment, health care and other services. For more

information call the New York State Division of Human Rights Office of AIDS Discrimination Issues at 1-800-523-2437 or (212)

480-2522 or the New York City Commission on Human Rights at (212) 306-7500. These agencies are responsible for protecting

your rights.

My questions about this form have been answered. I know that I do not have to allow release of my medical and/or HIV-related

information, and that I can change my mind at any time and revoke my authorization by writing the facility/person obtaining this

release. I authorize the facility/person noted on page one to release medical and/or HIV-related information of the person named

on page one to the organizations/persons listed.

Signature __________________________________________________________________ Date _____________________

(Subject of information or legally authorized representative)

If legal representative, indicate relationship to subject: _________________________________

Print Name _________________________________________________________________

Client/Patient Number_________________________________________________________

DOH-2557 (8/05) p 2 of 3

Form #PRIV-02-F01

orig – 10/31/03

reviewed 03/06, 04/08, 02/10

Page 3 of 4

Revised 03/11

Authorization For Disclosure Of Health Information Page 3