6. www.wcb.ny.gov. 3.Extent of Authorization a. If you are a recipient of the services funded by one of these covered programs, certain disclosures will require that you sign the Department's HIPAA-compliant Release form, by clicking here. Medical Records Release Authorization Form | HIPAA Create a high quality document online now! New York State department of Health - AIDS Institute Subject: Official consent form for the release of health information, including substance abuse information Keywords: hiv, aids, substance, drugs, alcohol, oasas, treatment, rehab, mental health, psychologist, psychiatrist, prevention, testing, hipaa Created Date: 5/2/2011 4:42:34 PM Rev. : 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 7. How information related to mental health is treated under HIPAA; When information related to mental health may be shared with family and friends of an individual with mental illness, including parents of minors; and The circumstances in which information related to mental health may be disclosed for health and safety purposes. Investigations / Regulatory Reporting Name and address of health provider or entity to release this information: 8. claimants are prohibited from authorizing release of workers' compensation information to prospective employers or in connection with assessing fitness or capability of employment.

_____ to _____ ** OR ** b. all past, present, and future periods. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.

Edit, fill, sign, download Authorization for Release of Health Information Pursuant to HIPPA - New York online on Handypdf.com. 7/4/03. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested. Page 1 of 3 HIPAA Release Form Please complete all sections of this HIPAA release form.

The official home page of the New York State Unified Court System. (if you know it):_____ To Claimant: If you received treatment for a previous injury to the same body part or for an illness similar to the one described in your current Claim, fill out this form We hear more than three million cases a year involving almost every type of endeavor. an incomplete form will delay the processing of your request. B-1. authorize AgeWell New York to discuss my health information with the entity or person(s) listed below: 2.Effective Period This authorization for release of information covers the period of healthcare form: a. The medical record information release (HIPAA), also known as the ‘Health Insurance Portability and Accountability Act’, is included in each person’s medical file. C-3.3 (12-09) www.wcb.ny.govLimited Release of Health Information (HIPAA) State of New York -Workers' Compensation Board C-3.3 WCB Case No. the New York State Office of Mental Health, nor will it affect my eligibility for benefits.

Page 1 of 3 HIPAA Release Form Please complete all sections of this HIPAA release form. The HIPAA release form must be completed and signed before a health care provider can release an individual’s healthcare information.The Health Insurance Portability and Accountability Act was created in 1996 with the sole purpose of protecting the personal information of each citizen’s medical information. HIPAA (Health Insurance Portability & Accountability Act) [fillable PDF - requires Acrobat 5 or newer] Note: The above two HIPAA forms may not be used to obtain an authorization for release of psychotherapy notes. Create Document. The Authorization of Health Release Form enables family, friends, or others to obtain health information relating to individuals in custody in the New York State Department of Corrections and Community Supervision (DOCCS). Use this form to enable NYC HRA to disclose protected health information to another party (such as an authorized representative). Pre-hospital Care Reports are medical records, and are confidential under Federal and New York State law and therefore FDNY follows specific guidance to ensure that patients’ records are confidential and only released to the patient or as required by law. This is the HIPAA release used by the Medicaid program in NYC.

NYCHHC HIPAA Authorization to Disclose Health Information PATIENT NAME/ADDRESS SPECIFIC INFORMATION TO BE RELEASED: NYCHHC HIPAA Authorization 2413, Revised 06-05 ALL FIELDS MUST BE COMPLETED NAME OF HEALTH PROVIDER TO RELEASE INFORMATION NAME & ADDRESS OF PERSON OR ENTITY TO WHOM INFO. … Refusing to sign this form will not prevent my ability to get treatment, payment, enrollment in health plan, or …