OCA Form 960 at a glance
What it is: OCA Official Form No.: 960 is the Authorization for Release of Health Information Pursuant to HIPAA, a form approved by the New York State Department of Health.
Who signs: The patient or representative authorized by law signs and dates after all items on this form have been completed and questions about this form have been answered; a copy of the form has been provided.
You, or your authorized representative, request that health information regarding your 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).
A filled-in OCA Form 960 example: a patient releases the entire medical record
How to fill out OCA Form 960, box by box
Patient Name, Date of Birth, Social Security Number and Patient Address
Enter the Patient Name, Date of Birth, Social Security Number and Patient Address.
7. Name and address of health provider or entity to release this information
In Item 7, enter the name and address of the health provider or entity to release this information.
You have the right to revoke this authorization at any time by writing to the health care provider listed in Item 7. You may revoke this authorization except to the extent that action has already been taken based on this authorization.
8. Name and address of person(s) or category of person to whom this information will be sent
Under 8, enter the name and address of the person(s) or category of person to whom this information will be sent.
9(a). Specific information to be released
Under 9(a), mark Medical Record from (insert date) to (insert date), 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, or Other.
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.
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 you place your initials on the appropriate line in Item 9(a). In the event the health information described in Item 9(a) includes any of these types of information, and you initial the line on the box in Item 9(a), you specifically authorize release of such information to the person(s) indicated in Item 8.
9(b). Authorization to Discuss Health Information
By initialing here, you authorize the individual health care provider listed in the Name of individual health care provider box to discuss your health information with your attorney, or a governmental agency, listed in the Attorney/Firm Name or Governmental Agency Name box.
This authorization does not authorize the health care provider to discuss your health information or medical care with anyone other than the attorney or governmental agency specified in Item 9 (b).
10. Reason for release of information
Under 10, mark the reason for release of information: At request of individual or Other.
11. Date or event on which this authorization will expire
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”.
12. If not the patient, name of person signing form, and 13. Authority to sign on behalf of patient
If not the patient, enter the name of person signing form under 12 and the authority to sign on behalf of patient under 13.
More rules for OCA Form 960
This form 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.
If you are authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without your authorization unless permitted to do so under federal or state law.
Information disclosed under this authorization might be redisclosed by the recipient (except as noted in Item 2), and this redisclosure may no longer be protected by federal or state law.
You have the right to request a list of people who may receive or use your HIV-related information without authorization. If you experience discrimination because of the release or disclosure of HIV-related information, you 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 your rights.
Signing this authorization is voluntary. Your treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon your authorization of this disclosure.
The form can be used more broadly than in litigation and be used before litigation has been commenced, or whenever counsel would find it useful.
The form is optional.
This form may be filled out on line and downloaded to be signed by hand, or downloaded and filled out entirely on paper.
Sources
[1] OCA Official Form No. 960, Authorization for Release of Health Information Pursuant to HIPAA, New York State Unified Court System (the Official source link on this page).
