AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
MRN: _______________________________
Date Received: _______________________
Date Processed: ______________________
Logged By:
Patient NameDate of BirthLast 4 # of SSN (if known)
Patient Address Phone Number
I, or my authorized representative, request that health care information be released as set forth on this form. In accordance with New York State (NYS) Law and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
1. This authorization may include the disclosure of health information relating to Alcohol/Drug/Substance Use Disorders or treatment, Mental Health treatment, except psychotherapy notes, HIV/AIDS treatment or testing, Genetic Testing and Reproductive Healthcare only if I place my initials on the appropriate line(s) on this form. If the health information described below includes any of these specific types of information, and I initial the line(s) on this form, I specifically authorize release of such information.
2. If I am authorizing the release of any information, including information relating to Alcohol/Drug/Substance Use Disorders or treatment, Mental Health treatment, HIV/AIDS treatment or testing, Genetic Testing or Reproductive Healthcare, the recipient is prohibited from re-disclosing such information without my authorization unless permitted to do so under Federal or NYS 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 NYS Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450.
3. Certain other health information disclosed under this authorization may be re-disclosed by the recipient and this re-disclosure may no longer be protected under Federal or NYS law.
4. I have the right to revoke this authorization at any time, in writing to Catholic Health. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization by Catholic Health.
5. Signing this authorization is voluntary and my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization.
6. Catholic Health may not release medical records or health information to anyone other than those listed on this authorization, unless permitted to do so without authorization under Federal or NYS law.
7. A person may be subject to criminal penalties pursuant to 42 USC §13 20d-6 if that person knowingly and in violation of HIPAA obtains individually identifiable health information relating to another individual or discloses such individually identifiable health information to another person.
Name of Catholic Health entity/provider to release health care information: (see Catholic Health, Medical Records website for addresses if needed)
Release/Send Health Information:
Name (and if applicable, address) of the individual (with title) and entity (if applicable) to whom this health information will be disclosed:
Select Format: £ Verbal £ Paper (Mail) £ CD (Mail) £ Fax (include number): __________________________________________
£ E-delivery (requester email address): __________________________________________________________________________________ Note: E-delivery is processed via Catholic Health’s Release of Information Third Party System.
Type of Health Information (select one):
£ Medical Record / Health Information from (date) ____________________ to (date) ____________________.
£ Complete Medical Record / Health Information, including patient histories, encounter notes (except psychotherapy), test results, radiology studies, films, referrals, consults, insurance or billing records and other records from Catholic Health.
£ Other/Specific: ____________________________________________________________________________________________________
*Include Health Information related to (initial each line for specific information requested): ________ Alcohol/Drug/Substance Use Disorder Info. ________ Mental Health Information ________ HIV-related Information ________ Genetic Testing Information ________ *Reproductive Health Information (see attestation below)
Reason for release of information (select all that apply): £ Patient/Personal Rep. Request £ Treatment/Care Coordination
£ Training/Education/Journal £ Legal £ Marketing/Fundraising £ Other: ____________________________________________________
Authorization Expiration: (if left blank, authorization will not expire or change unless requested) _______ One Time Only _____________ Date _________________________ Event
All items on this form have been completed to the best of my ability and my questions about this form have been answered. I have been provided with a copy of this form upon my request.
For disclosures that include Reproductive Health Information: I understand that HIPAA prohibits the use or disclosure of reproductive health information when it is sought to investigate or impose liability on individuals, health care providers, or others who seek, obtain, provide, or facilitate reproductive health care. I attest that this request is not made for the purpose of investigation or imposition of liability in connection with reproductive health care. I understand I may be requested to sign additional and/or separate attestations.
Patient/Personal Representative: Signature: ________________________________________________ Date & Time:________________________
*If Personal Representative - Relationship to/Authority to Act on Behalf Of Patient Personal Representative Contact Information (if different from above)