We will not re-disclose any previous provider records or records that did not originate in our office. If you need records from a previous provider, a specialist, an outside agency, etc. you will need to request records from them. The witness statement at the bottom of the document only applies if you are filling out the form in the office.
Any copies sent directly to you will be subject to a fee. Please contact our medical records department for further information. Records for personal use will be sent on a CD with instructions on how to access them sent separately.
Please fill out the school information including fax number in box #6. If there is no fax number listed, we cannot send your records. If you are only releasing certain information, like the most recent physical and mediation information, please indicate what you would like shared in section #8. Do not check the “All health information” box and write “Only medication information and dosing” or “Only school physicals”, etc.
We will send records to other providers’ offices and government agencies on CD or by fax at no charge. Instructions on how to access them are mailed separately
Please use OCA Official Form no. 960 that can be found online at https://nycourts.gov/forms/hipaa_fillable.pdf There will be a charge for these records.
(Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AID related Information
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:
8. Unless previously revoked by me, the specific information below may be disclosed from:
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All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
This form may be used in place of DOH2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Abuse Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatmentrelated information or confidential HIVrelated information released through this form must be accompanied by the required statements regarding prohibition of redisclosure.
*Note: Information from mental health clinical records may be released pursuant to this authorization to the parties identified herein who have a demonstrable need for the information, provided that the disclosure will not reasonably be expected to be detrimental to the patient or another person.
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