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 rega rding 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 toALCOHOL 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 informatio n described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize rel ease 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 informati on, the recipient is prohibited from redisclosing such information without my authorization u nless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may rec eive 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 understa nd that I may revoke this authorization except to the extent that action has already b een taken based on this authorization. 4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility fo r benefits will not be conditioned upon my authorization of this disclosur e. 5. Information disclosed under this authorization might be redisclosed by t he recipient (except as notedabove 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 INFORMATI ON OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIE D IN ITEM 9 (b). 7. Name and address of health provider or entity to release this informa tion: 8. Name and address of person(s) or category of person to whom this 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 (excep t psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, an d 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: 11. Date or event on which this authorization will expire: q At request of individual q Other: 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 reg arding a persons contacts. >>>> 2 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 HIPAAPrivacy 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 f his or her entire medical record, buto 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.