AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health] HIPAA Authorization for Release of Health Information Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Email(Required) Phone(Required)Social Security Number(Required) Patient Address(Required) Address Line 1 Address Line 2 City State Zip / Postal Code 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: 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 9(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 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8. 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 (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting 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 redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. 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 9 (b).7. Name and address of health provider or entity to release this information:(Required) Me or to Name Of Person or Entity 8. Name of person(s) or category of person to whom this information will be sent:(Required) Address of person(s) or category of person to whom this information will be sent:(Required) Address Line 1 Address Line 2 City State Zip / Postal Code Phone(Required)Fax Email(Required) Hidden9(a). Information to Release Date(s)(Required) Medical Record from (insert date) From Date(Required) MM slash DD slash YYYY To Date(Required) MM slash DD slash YYYY (Required) Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers. Disclosure of Sensitive InformationYou have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing. Include (Indicate by checking below): Mental Health Testing/Treatment (except psychotherapy notes) Alcohol/Drug Treatment/Testing HIV/AIDS Related Information Genetic Testing Information Please note that the information will not be released if not checked.(Required) I authorize the disclosure of ALL sensitive information I DO NOT authorize the disclosure of ANY sensitive information Delivery Methods(Required) Receive electronic copy of records of Email Mail Paper Records Fax Patient Portal* * Patients with an active electronic medical records account (patient portal) can request electronic delivery via secure web patient portal at no cost. Please confirm by checking the box above.9(b). Authorization to Discuss Health Information(Required) By initialing here I authorize Name of individual health care provider(Required) to discuss my health information with my attorney, or a governmental agency, listed here:(Required) Address of person(s) or category of person to whom this information will be sent:(Required) Address Line 1 Address Line 2 City State Zip / Postal Code 10. The purpose(s) for which disclosure is authorized (check where applicable):(Required) Patient’s request Care at another facility / provider Life Insurance Legal Disability Work’s Comp Other Specify Other 11. Date or event on which this authorization will expire:(Required) 12. If not the patient, name of person signing form 13. Authority to sign on behalf of patient (i.e., parent, power of attorney, etc.) Power of Attorney Parents or Patient's Guardians Other Other(Required) Please upload Power of Attorney/Estate Administration Letters(Required)Max. file size: 128 MB.14. Is patient deceased?(Required) Yes No File(Required)Max. file size: 128 MB. 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.(Required)Date(Required) MM slash DD slash YYYY * 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.(Required) I hereby certify that, to the best of my knowledge, the provided information is true and accurate.