Fillable Printable Authorization for Release of Health Information Pursuant to HIPPA - New York

Authorization for Release of Health Information Pursuant to HIPPA - New York

OCA Official Form No.: 960

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA

[This form has been approved by the New York State Department of Health]

Patient Name Date of Birth Social Security Number

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 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.

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 (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are

responsible for protecting my rights.

3. 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.

4. 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.

5. 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.

6. 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:

8. Name and address of person(s) or category of person to whom th is information will be sent:

9(a). Specific information to be released:

q Medical Record from (insert date) ___________________ to (insert date) ___________________

q 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.

q Other: __________________________________ Include: (Indicate by Initialing)

__________________________________ ________ Alcohol/Drug Treatment

________ Mental Health Information

Authorization to Discuss Health Information ________ HIV-Related Information

(b) q By initialing here ____________ I authorize ________________________________________________________________

Initials Name of individual health care provider

to discuss my health information with my attorney, or a governmental agency, listed here:

______________________________________________________________________________________________________

(Attorney/Firm Name or Governmental Agency Name)

10. Reason for release of information:

q At request of individual

q Other:

11. Date or event on which this authorization will expire:

12. If not the patient, name of person signing form: 13. 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.

______________________________________________ Date: _____________________________

Signature of patient or representative authorized by law.

* 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.

Instructions for the Use

of the HIPAA-compliant Authorization Form to

Release Health Information Needed for Litigation

This form is the product of a collaborative process between the New York State

Office of Court Administration, representatives of the medical provider community in

New York, and the bench and bar, designed to produce a standard official form that

complies with the privacy requirements of the federal Health Insurance Portability and

Accountability Act (“HIPAA”) and its implementing regulations, to be used to authorize

the release of health information needed for litigation in New York State courts. It can,

however, be used more broadly than this and be used before litigation has been

commenced, or whenever counsel would find it useful.

The goal was to produce a standard HIPAA-compliant official form to obviate the

current disputes which often take place as to whether health information requests made in

the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be

noted, though, that the form is optional. This form may be filled out on line and

downloaded to be signed by hand, or downloaded and filled out entirely on paper.

When filing out Item 11, which requests the date or event when the authorization

will expire, the person filling out the form may designate an event such as “at the

conclusion of my court case” or provide a specific date amount of time, such as “3 years

from this date”.

If a patient seeks to authorize the release of his or her entire medical record, but

only from a certain date, the first two boxes in section 9(a) should both be checked, and

the relevant date inserted on the first line containing the first box.