Lily W. Eng, DDS

101 Lafayette Street, 9th Floor, New York, NY 10013

212-842-5300, 212-842-8042

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS-related Information


Patient Name:
Date of Birth:
Patient Identification Number:
Patient Address:
Email Address:
Phone:

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:

  1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS-RELATED INFORMATION only if I place my initials on the appropriate line in item 8. 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 8, I specifically authorize release of such information to the person(s) indicated in Item 6.
  2. With some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS- related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS-related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights.
  3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.
  4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.
  5. Name and Address of Provider or Entity to Release this Information:
  6. Name and Address of Person(s) to Whom this Information Will Be Disclosed:
  7. Purpose for Release of Information:
  8. Unless previously revoked by me, the specific information below may be disclosed
    From:
    Untill:
    For the following to be included, indicate the specific information to be disclosed and initial below.
    Information to be Disclosed Initials
  9. If not the patient, name of person signing form:
  10. Authority to sign on behalf of patient:


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.


SIGNATURE OF PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW

Use your mouse cursor or the tip of your finger to sign below

Date :

Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient’s authorized representative.

SIGNATURE:

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Date:
Staff person's name and title :

This form may be used in place of DOH-2557 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 treatment-related information or confidential HIV-related information released through this form must be accompanied by the required statements regarding prohibition of re-disclosure.

*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.