Authorization For Disclosure Of Health Information Page 4

ADVERTISEMENT

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. Blank lines may 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:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
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:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If any/all of this page is completed, please sign below:
Signature _________________________________________________________________ Date _________________
Client/Patient Number________________________________________________________
DOH-2557 (8/05) p 3 of 3
Form #PRIV-02-F01
orig – 10/31/03
reviewed 03/06, 04/08, 02/10
Page 4 of 4

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Authorization For Disclosure Of Health Information Authorization For Disclosure Of Health Information Legal
Authorization For Disclosure Of Health Information Authorization For Disclosure Of Health Information Legal
Authorization For Disclosure Of Health Information Form - Minnesota Student Health Services Authorization For Disclosure Of Health Information Form - Minnesota Student Health Services Medical
Form Mr-465-8 Nis-authorization For Disclosure Of Health Information Form Form Mr-465-8 Nis-authorization For Disclosure Of Health Information Form Business
Ca Request And Authorization For Disclosure Of Health Information Ca Request And Authorization For Disclosure Of Health Information Medical
Authorization For Disclosure Of Protected Health Information And Other Information Authorization For Disclosure Of Protected Health Information And Other Information Business
Authorization For Disclosure Of Protected Health Information - Hospital Authorization For Disclosure Of Protected Health Information - Hospital Legal
Authorization For Disclosure Of Protected Health Information Authorization For Disclosure Of Protected Health Information Legal
Authorization For Use And Disclosure Of Health Information Authorization For Use And Disclosure Of Health Information Medical
Authorization For Use Or Disclosure Of Health Information Authorization For Use Or Disclosure Of Health Information Business

Related Categories

Parent category: Medical
Download
Go
Page of 4