Omh Form PDF Details

Understanding the intricacies of managing personal health information, especially within the context of mental health, is crucial for ensuring that sensitive data is handled with respect and privacy. The State of New York's Office of Mental Health provides a framework through Form OMH 11 for patients or their personal representatives to authorize the release of such information. This form is essential for individuals seeking to have their mental health information disclosed to designated parties, under conditions that safeguard their privacy according to state and federal laws. Through a meticulous authorization process, the form outlines the types of information that can be disclosed, the purposes of such disclosure, and the parties involved in the exchange of information. It emphasizes the confidentiality of the disclosed information, protecting it under the Health Insurance Portability and Accountability Act (HIPAA) and the New York State Mental Hygiene Law. Moreover, it grants patients the power to revoke their authorization at any point, ensuring that they remain in control of their personal health information. This form serves as a vital tool for managing consent in the disclosure of mental health records, highlighting the balance between the need for information sharing and the importance of privacy protections.

QuestionAnswer
Form NameOmh Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow to omh form, omh form, omh 11 form, ny omh forms

Form Preview Example

Form OMH 11 (＜-10)

State of New York

 

OFFICE OF MENTAL HEALTH

AUTHORIZATION FOR

RELEASE OF INFORMATION

Patient’s Name (Last, First, M.I.)“C” No.

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sex

. Date of Birth

Facility Name

Unit/Ward/Residence No.

This authorization must be completed by the patient or his/her personal representative to use/disclose protected health information, in accordance with State and federal laws and regulations. Information 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. A separate authorization is required to use or disclose confidential HIV related information.

PART 1: Authorization to Release Information

Description of Information to be Used/Disclosed:

Purpose or Need for Information:

1.This information is being requested:

❏by the individual or his/her personal representative for release to a person or entity with a demonstrable need for the information; or

❏Other (please describe) _______________________________________________________________________

2.The purpose of the disclosure is (please describe):

From: Name, Address, & Title of Person/ Organization/Facility/Program Disclosing Information

_________________________________________________

_________________________________________________

_________________________________________________

To: Name, Address, & Title of Person/Organization/Facility/ Program to Which this Disclosure is to be Made

NOTE: If the same information is to be disclosed to multiple parties for the same purpose, for the same period of time, this authorization will apply to all parties listed here.

________________________________________________

________________________________________________

________________________________________________

A.I hereby permit the use or disclosure of the above information to the Person/Organization/Facility/Program(s) identified above. I understand that:

1.Only the information described in this form may be used and/or disclosed as a result of this authorization.

2.This information is confidential and is protected under federal privacy regulations (HIPAA) and the NYS Mental Hygiene Law and cannot legally be disclosed without my permission.

3.If this information is disclosed to someone who is not required to comply with HIPAA, then it could be redisclosed and would no longer be protected by HIPAA. However, this information will still be protected under the NYS Mental Hygiene law, which prohibits this information from being redisclosed by anyone who receives it unless the redisclosure is per­ mitted by the NYS law (Mental Hygiene Law＃§33.13).

4.I have the right to revoke (take back) this authorization at any time. My revocation must be in writing on the form provided to me by (insert name of facility/program) _______________________________________________________________ . I am aware that my revocation will not be effective if the persons I have authorized to use and/or disclose my protected health information have already taken action because of my earlier authorization.

5.I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the New York State Office of Mental Health, nor will it affect my eligibility for benefits.

6.I have a right to inspect and copy my own protected health information to be used and/or disclosed (in accordance with the requirements of the federal privacy protection regulations found under 45 CFR §164.524 and NYS Mental Hygiene Law §33.16.

B-1. One-Time Use/Disclosure: I hereby permit the one-time use or disclosure of the information described above to the person/ organization/facility/program identified above.

My authorization will expire:

❏ When acted upon; ❏ 90 Days from this Date; ❏ Other____________________________________________

Continue on Next Page ➔

Form OMH 11 (＜-10) page 2

AUTHORIZATION FOR RELEASE OF INFORMATION

 

State of New York

 

OFFICE OF MENTAL HEALTH

 

 

 

 

 

Facility/Agency Name

 

Patient’s Name (Last, First, M.I.)

 

“C”/Id. No.

 

 

 

 

 

B-2. Periodic Use/Disclosure: I hereby authorize the periodic use/disclosure of the information described above to the person/ organization/facility/program identified above as often as necessary to fulfill the purpose identified above.

My authorization will expire:

❏When I am no longer receiving services from (insert name of facility/program) __________________________ ;

❏One year from this date;

❏Other _____________________________________________________________________________________

C. Patient Signature: I certify that I authorize the use of my health information as set forth in this document.

___________________________________________________________________________________

____________________________________

Signature of Patient or Personal Representative

Date

___________________________________________________________________________________

Patient’s Name (Printed)

___________________________________________________________________________________

Personal Representative’s Name (Printed)

______________________________________________________________________________________________________________________________

Description of Personal Representative’s Authority to Act for the Patient (required if Personal Representative signsAuthorization)

D.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 personal representative.

WITNESSED BY: __________________________________________________

Staff person’s name and title

Authorization Provided To: ___________________________________________

Date: ___________________________________________________________

To be Completed by Facility:

________________________________________________________________________________________

Signature of Staff Person Using/Disclosing Information

________________________________________________________________________________________

Title

________________________________________________________________________________________

Date Released

PART 2: Revocation of Authorization to Release Information

I hereby revoke my authorization to use/disclose information indicated in Part I, to the Person/Organization/Facility/Program whose name and address is:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

I hereby refuse to authorize the use/disclosure indicated in Part I, to the Person/Organization/Facility/Program whose name and address is:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

______________________________________________________________________________________________________

________________________________________________________________________________

______________________________________________

Signature of Patient or Personal Representative

Date

________________________________________________________________________________

 

Patient’s Name (Printed)

 

________________________________________________________________________________

Personal Representative’s Name (Printed)

____________________________________________________________________________________________________________________________________

Description of Personal Representative’s Authority to Act for the Patient (required if Personal Representative signs Revocation ofAuthorization)

How to Edit Omh Form Online for Free

how to omh information can be filled out online without difficulty. Just try FormsPal PDF editing tool to accomplish the job without delay. The tool is consistently updated by our team, getting new functions and turning out to be better. If you're looking to start, here's what it takes:

Step 1: Click on the "Get Form" button in the top section of this page to access our PDF tool.

Step 2: With the help of this handy PDF tool, you may do more than merely fill in blanks. Try all the features and make your documents look great with custom textual content added, or fine-tune the original input to perfection - all that accompanied by the capability to add stunning pictures and sign the file off.

This form will need particular information to be entered, therefore ensure you take the time to fill in what's required:

1. Start filling out your how to omh information with a number of necessary blanks. Note all the important information and make certain there's nothing omitted!

Stage # 1 in submitting omh forms

2. Soon after finishing the previous step, go on to the subsequent stage and enter the necessary particulars in all these blanks - Other please describe, The purpose of the disclosure is, From Name Address Title of Person, To Name Address Title of, NOTE If the same information is to, I hereby permit the use or, Only the information described in, This information is confidential, Law and cannot legally be, If this information is disclosed, would no longer be protected by, and I have the right to revoke take.

The way to fill in omh forms stage 2

It's very easy to get it wrong while filling out the From Name Address Title of Person, and so be sure you reread it before you'll submit it.

3. This stage is usually straightforward - fill in every one of the blanks in I have the right to revoke take, I do not have to sign this, the New York State Office of, I have a right to inspect and, B OneTime UseDisclosure I hereby, organizationfacilityprogram, My authorization will expire, When acted upon Days from this, and Continue on Next Page to conclude this segment.

Ways to complete omh forms step 3

4. To go ahead, this fourth stage will require completing a handful of fields. These comprise of AUTHORIZATION FOR RELEASE OF, FacilityAgency Name, Patients Name Last First MI, OFFICE OF MENTAL HEALTH, CId No, B Periodic UseDisclosure I hereby, organizationfacilityprogram, My authorization will expire, When I am no longer receiving, One year from this date, Other, C Patient Signature I certify that, Signature of Patient or Personal, Date, and Patients Name Printed, which you'll find vital to carrying on with this document.

Writing part 4 of omh forms

5. Because you near the completion of this document, there are actually several more requirements that should be met. Mainly, Date, To be Completed by Facility, Signature of Staff Person, Title, Date Released, PART Revocation of Authorization, I hereby revoke my authorization, and I hereby refuse to authorize the should be filled in.

Completing section 5 of omh forms

Step 3: Right after you've looked once again at the information in the blanks, just click "Done" to finalize your form at FormsPal. Go for a 7-day free trial subscription with us and obtain direct access to how to omh information - downloadable, emailable, and editable from your personal cabinet. FormsPal offers risk-free form editor with no personal data record-keeping or distributing. Rest assured that your details are safe here!

Omh Form isn’t the one you’re looking for?

Related Documents