As a business, you likely have several HIPAA release forms to protect your patients' information. But are you sure that all of your employees are fully aware of the form's purpose and their responsibilities in regards to it? It's important to make sure that everyone who could potentially access patient data understands their role in protecting confidentiality. A HIPAA release form is one of the most important tools you have for safeguarding sensitive information, so make sure everyone on your team knows how to use it properly.
Below is the information concerning the PDF you were looking for to complete. It can tell you how long it will need to finish hipaa release form, what parts you need to fill in, and so on.
| Question | Answer |
|---|---|
| Form Name | Hipaa Release Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form hipaa release, form official hipaa, 960 form hipaa official, ny form hipaa |
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]
Patient Name
Date of Birth
Social Security Number
Patient Address
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:
1.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 place my initials 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.
2.If I am authorizing the release of
3.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.
4.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.
5.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.
6.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 health provider or entity to release this information:
8.Name and address of person(s) or category of person to whom this information will be sent:
9(a). Specific information to be released: |
|
|
|
|
|
|||
|
|
Medical Record from (insert date) |
|
|
to (insert date) |
|
|
|
|
|
|
|
|
|
|||
|
|
Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test result, radiology studies, films, |
||||||
|
|
|||||||
|
|
referrals, consults, billing records, insurance records, and records sent to you by other health care providers. |
||||||
|
|
Other: |
|
|
|
|
Include: (Indicate by Initialing) |
|
|
|
|
|
|
||||
|
|
|
|
|
|
|
|
|
Alcohol/Drug Treatment |
|
|
|
|
|
|
|
|
|
Mental Health Information |
Authorization to Discuss Health Information |
|
|
|
||||||
(b) |
|
By initialing here |
|
I authorize |
|
|
|
|
|
|
|
|
|
|
|
||||
|
|
|
|
Initials |
|
Name of individual health care provider |
|||
to discuss my health information with my attorney, or a governmental agency, listed here:
|
|
|
(Attorney/Firm Name or Governmental Agency Name) |
|
|
|
|
|
|
10. Reason for release of information: |
|
11. Date or event on which this authorization will expire: |
||
|
|
At request of individual |
|
|
|
|
|
|
|
|
|
Other: |
|
|
|
|
|
|
|
|
|
|
|
|
12. If not the patient, name of person signing form: |
|
13. Authority to sign on behalf of patient: |
||
|
|
|
|
|
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.
Date:
Signature of patient or representative authorized by law.
*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.
NYHIPAA 8/09
Instructions for the Use
of the HIPAA compliant Authorization Form to Release Health Information Needed for Litigation
This form is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act (“HIPAA”) and its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful.
The goal was to produce a standard
When filing out Item 11, which requests the date or event when the authorization will expire, the person filling out the form may designate an event such as “at the conclusion of my court case” or provide a specific date amount of time, such as “3 years from this date”.
If a patient seeks to authorize the release of his or her entire medical record, but only from a certain date, the first two boxes in section 9(a) should both be checked, and the relevant date inserted on the first line containing the first box.
NYHIPAAB 8/09