AUTHORIZATION FOR RELE ASE OF H EALTH INFORMATION PURSUANT T O Hl PAA
[This form h2s been a p proved by the New York S tate Depart m ent o f Health I
Date o fBi rth Social Security Number
8( t.81 l9S'.:l--
Patient Address
rlO Anch·ews
l, or my authorized representative, request that health information regarding my care and treatment as set forth·on this form:
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(H l PA A), 1 understand that:
I. This authorization may include disclosure of information relating to ALCOHOL and DRUG A BUSE, M ENTA L HEALTH
T REATMENT , except psychotherapy notes, and C O NF IDENTl AL HIV* RELATED I NFORMATION 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 1
initial the line on the box in Item 9(a), I s peci fically authorize rele ase of such information to the person(s) ind icated in Item 8.
2 . If l am authorii.ing 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 in formation without authorization. !fl
experience discrimination because of the release or disclosure of HIV-related information, l may contac t 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. 1 have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revo ke th is authorization except to the extent that action has already been taken based on this authorization.
4. I understand that sign ing this authorization is voluntary. My treahnent, payment, enrollmen t in a health plan, or e ligib.ility 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 n o longer be protected by federal or state law.
6. TH IS AUTHO RI ZAT IO N DOES NOT AUT H O RIZ E YOU TO DISCUSS MY H E ALTH INFORMAT IO N OR MEDIC AL
CARE WITH ANYONE OTH E R T HAN T HE ATTORNEY OR GOVERNMENT AL AGENCY S P ECIFIE D I N ITEM 9 b.
8.
9(a). Specific information to be released:
~edical Record form (insert date) A\?r't'(
'2..C2<-) to (insert date) i'/\.0..\( 10'2.l--)
a Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies,
V films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
,<., Other: D!scha. rqc fl Qt( I l'..M,{o(~ ~us Include: (Indicate by Initialing)
CDs ____.AlcohoVDrug T r ea tmen t
_ _ _ _Meotal Health l n fo nnation
_ __ _ HIV- Related Iu formation
Authoriution to Discuss Hn lth Info r mation
(b). □ By in itialing here_ _ __ !, authorize _ __ _ __ __ __ __ _ _ _ _____ __ __ __ _ __ _
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:
Attome /Finn or Govemmcotal A enc Name
I 0. Reason for release of information: 11. Date or event on which th is authorization wi ll ex pire:
)(At request of individual
o Other:
12. lfnot the patient, name of person signing form: I 3. Authority to sign on behal fof patient:
All Items on this form have been completed and my questions about this form have been answered. I n addition, I have been provided a
copy of the form.
July 9, 2024
Date: _ __ _ __ _ _ _ _ __ _ _ __
Signature of Patient or representative authorized by law.
• Human lmmu nodtficit ncy Virus that ause:~ AIDS. T he. N t w York St:ate Public Kuilth L1w protcct.5 iorormation which rtlson1bly cou ld idt ntiry somtone. as
having HIV sympcoms or infection and Information regarding a pu soo's contacu.
