At the heart of managing personal health information and safeguarding privacy within the workplace lies the crucial EHS-742 form, a document that serves as an authoritative gateway for the release and disclosure of medical records. Produced by the New York State Department of Civil Service Employee Health Service, its primary aim is to ensure a structured process for individuals seeking to share their health information under specific circumstances. Whether it's for personal use, evaluating an individual's ability to perform job duties, or other specified reasons, this form lays down a clear path for such disclosures. It is steeped in legal considerations, guided by the tendrils of the Personal Privacy Protection Law, indicating the significance of its role in protecting both the entity requesting the release and the individual whose information is being disclosed. From specifying the nature of the records requested to identifying the recipients of this sensitive information, the form encapsulates a high degree of responsibility and confidentiality. Moreover, it underscores the impermanent nature of this authorization, which can be revoked, highlighting the rights individuals retain over their personal information. Misunderstanding or neglecting the provisions laid out in this document not only jeopardizes the privacy and security of one’s medical data but can also impede the necessary flow of information that supports health and employment-related decisions.
| Question | Answer |
|---|---|
| Form Name | Ehs 742 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | Cohoes, NY, NYS, form filling typing |
NYS Department of Civil Service
Employee Health Service
55 Mohawk Street - Suite 201
Cohoes, NY 12047
(518)
Authorization for Release and
Disclosure of Medical Information
(Please Print Clearly) |
INFORMATION CONCERNING |
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Last Name |
First Name |
M.I. |
Date of Birth
Social Security #
Street Address |
City |
State |
Zip Code |
Personal Privacy Protection Law - The information which you provide on this form is being requested pursuant to Section 82..3 of the Regulations of the Department of Civil Service (President's Regulations) for the principal purpose of processing the release of your medical records (4NYCRR 82.3). This information will be used in accordance with Section 96 (1) of the Personal Privacy Protection Law, particularly subdivisions (b), (e), and (f). Failure to provide the information requested may prevent your medical records from being released. This information will be maintained by the Administrator of the Employee Health Service, NYS Department of Civil Service, 55 Mohawk Street - Suite 201, Cohoes, NY 12047. For further information relating only to the Personal Privacy Protection Law, call (518)
AUTHORIZATION FOR RELEASE AND DISCLOSURE OF MEDICAL INFORMATION
I, ___________________________________________, authorize release or disclosure of the following medical records:
EHS Nurse records of: __________________________________________________________________________________
(Date(s)
EHS Medical records of:__________________________________________________________________________________
(Date(s)
Personal Physician's records pertinent to: _____________________________________________________________________
(Medical Condition)
Other _________________________________________________________________________________________________
THESE RECORDS WILL BE USED FOR:
My Personal Use |
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By EHS to Determine Your Ability to Perform the Duties of Your Position |
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____________________________________________________________ |
________________________________________ |
Signature |
Date |
This information may be
This authorization expires is 90 days or on:____________________________. You may revoke this authorization by writing to the EHS Privacy
Official at the address at the top of this page unless the EHS has already released or disclosed the information for the purpose(s) noted above. Please
make sure you receive a copy of this authorization after you sign it.
SEND RECORDS |
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SEND RECORDS |
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Employee Health Service |
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Employee Health Service |
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NYS Department of Civil Service |
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NYS Department of Civil Service |
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55 Mohawk Street – Suite 201 |
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55 Mohawk Street – Suite 201 |
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Cohoes, NY 12047 |
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Cohoes, NY 12047 |
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Physician, Hospital, Other |
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Physician, Attorney, Self, Other |
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Copies: |
EHS (white) |
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EMPLOYEE (Pink) |
OTHER (Yellow) |
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