Authorization for Release of Health Information Pursuant to HIPAA

Please correct the errors described below.

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 Testability 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 the 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 disclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.

9(a). Specific information to be released:

Authorization to Discuss Health Information

9. (b) By initialing here


i authorize

(Attorney/Firm Name or Governmental Agency Name)

10. Reason for release of information:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

*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 S.. Office of Co. 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 comae 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 online and downloaded to be signed by hand, or downloaded and filled out entirely on paper.

When filling out Item II, 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 ease" 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 fine containing the first box.

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