New York State Department of Health
AIDS Institute
HIPAA Compliant Authorization for Release of Medical Information
and Confidential HIV* Related Information
This form authorizes release of medical information including HIV-related information. You may choose to release just your non-HIV medical
information, just your HIV-related information, or both. Your information may be protected from disclosure by federal privacy law and state law.
Confidential HIV-related information is any information indicating that a person has had an HIV-related test, or has HIV infection, HIV-related
illness or AIDS, or any information that could indicate a person has been potentially exposed to HIV.
Under New York State Law HIV-related information can only be given to people you allow to have it by signing a written release. This information
may also be released to the following: health providers caring for you or your exposed child; health officials when required by law; insurers to
permit payment; persons involved in foster care or adoption; official correctional, probation and parole staff; emergency or health care staff who
are accidentally exposed to your blood, or by special court order. Under State law, anyone who illegally discloses HIV-related information may be
punished by a fine of up to $5,000 and a jail term of up to one year. However, some re-disclosures of medical and/or HIV-related information are
not protected under federal law. For more information about HIV confidentiality, call the New York State Department of Health HIV Confidentiality
Hotline at 1-800-962-5065; for information regarding federal privacy protection, call the Office for Civil Rights at 1-800-368-1019.
By checking the boxes below and signing this form, medical information and/or HIV-related information can be given to the people listed on page
two (or additional sheets if necessary) of the form, for the reason(s) listed. Upon your request, the facility or provider disclosing your medical
information must provide you with a copy of this form.
I consent to disclosure of (please check all that apply):
My non-HIV medical information
My HIV-related information
Both (non-HIV medical and HIV-related information)
Facility/Provider Disclosing Information Must Complete Box Below:
Name and address of facility/provider disclosing HIV-related and/or medical information:
________________________________________________________________________________________________
________________________________________________________________________________________________
Name of person whose information will be released: __________________________________________________________
Name and address of person signing this form (if other than above):
______________________________________________________________________________________________
______________________________________________________________________________________________
Relationship to person whose information will be released:___________________________________________________
______________________________________________________________________________________________
Describe information to be released:______________________________________________________________________
Reason for release of information: _______________________________________________________________________
Time Period During Which Release of Information is Authorized From: _____________________
To: __________________
Exceptions, if any, to the right to revoke consent for disclosure (for example, cannot revoke if disclosure has already been made):
________________________________________________________________________________________________
________________________________________________________________________________________________
Description of the consequences, if any, of failing to consent to disclosure upon treatment, payment, enrollment, or eligibility for benefits
(Note: Federal privacy regulations may restrict some consequences):
________________________________________________________________________________________________
________________________________________________________________________________________________
*Human Immunodeficiency Virus that causes AIDS
DOH-2557 (4/05) p 1 of 3
Please Complete Information on Page 2.
HIPAA Compliant Authorization for Release of Medical Information
and Confidential HIV* Related Information
Complete information for each provider 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 1:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If information to be disclosed to this provider 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 1:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If information to be disclosed to this provider 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) 480-2493 or the New York City
Commission of Human Rights at (212) 306-5070. 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/provider obtaining this release.
I authorize the facility/provider 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 __________________________________________________________________
Print Name _________________________________________________________________
Client/Patient Number_________________________________________________________
DOH-2557 (4/05) p 2 of 3
Date_____________________
HIPAA Compliant Authorization for Release of Medical Information
and Confidential HIV* Related Information
Complete information for each provider 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 1:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If information to be disclosed to this provider 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 1:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If information to be disclosed to this provider 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 1:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
If information to be disclosed to this provider is limited, please specify:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
DOH-2557 (4/05) p 3 of 3
