Third Party Request to Access Form - Bronx Treatment Center

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]

To request access to or the release of your protected health information (PHI), please complete and return the following Authorization for Release of Health Information Pursuant to HIPAA form. This form allows you to authorize us, as a covered healthcare provider, to disclose your medical information to a designated individual, organization, or entity. To ensure compliance with federal privacy regulations, all required fields must be completed accurately and the form must be signed and dated by the patient or their authorized representative. Please note that certain disclosures, such as those for legal, insurance, or personal use, cannot be processed without a valid authorization on file.

Patient's First Name (Required)

Patient's Last Name (Required)

Date of Birth (Required)

Contact phone# (Required)

Postal Address (Required)

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 Portability and Accountability Act of 1996 (HIPAA), I understand that:

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 check the boxes 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 release of such information to the person(s) indicated in Item 8.
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.
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.
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.
Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.
THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).

7. Name and address of Bronx Treatment Center provider or location to release this information

8. Name and address of person or organization to whom this information will be sent

The Date(s) of Service requested (Required)

From Date (Required)

To Date (Required)

Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.

Disclosure of Sensitive Information

Please indicate by checking the box below whether you would like us to disclose sensitive information related to the following conditions, treatments, or testing:

Mental Health Testing/Treatment (except psychotherapy notes)

Alcohol/Drug Treatment/Testing

HIV/AIDS Related Information

Genetic Testing Information

Please note that the sensitive information will not be released if not checked.

I authorize the disclosure of ALL sensitive information

I DO NOT authorize the disclosure of ANY sensitive information

Delivery Method - Send By(Required)

9(b). Authorization to Discuss Health Information(Required)

By initialing here

I authorize (name of Bronx Treatment Center Provider)

to discuss my health information with my attorney, or a governmental agency, listed here

10.The purpose(s) for release of this information

Specify Other

11. Date or event on which this authorization will expire (Required)

12. If not the patient, name of person signing form

13. Authority to sign on behalf of patient (i.e., parent, power of attorney, etc.)

Power of Attorney

Parents or Patient's Guardians

Other

Other (Required)

14. Is patient deceased? (Required)

Yes

All items on this form have been completed and my questions about this form have been answered.

Signature of patient or representative authorized by law.(Required)

Date (Required)

*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.

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.