Follow the steps to complete the DOH-5173 * - Health Ny form online

1. Press the ‘Get Form’ button to obtain the DOH-5173 * - Health Ny form and open it in the editor for completion.
2. In the top box, ensure to fill in your personal details, including your full name, date of birth, and last four digits of your Social Security number. Verify that the information is correct and make adjustments as necessary.
3. Enter your address and Client ID Number (CIN), as well as your Disability ID Number (DIN) in the designated fields.
4. In Section 7, write the name and address of the healthcare provider who will send your health records to the State Disability Review Unit.
5. In Section 8, confirm that the designated recipient is the State Disability Review Unit, which should already be filled in for you.
6. For Section 9(a), specify the information to be released by checking the appropriate box. This could include medical records for a certain period or an entire medical record.
7. If you wish to authorize your healthcare provider to discuss health information with the State Disability Review Unit, initial the provided space in Section 9(b) and include the name of the healthcare provider.
8. In Section 9(c), indicate the types of medical information you do not consent to disclose by checking the relevant boxes.
9. For Section 10, check the box that applies to the reason for the release of information and provide any additional context if necessary.
10. In Section 11, specify that the purpose of the use or disclosure is for disability determination and review.
11. If you are not the patient, print your name in Section 12.
12. In Section 13, provide your relationship to the patient if you are signing on their behalf.
13. After completing all sections, review the entire form for accuracy. Finally, sign and date the form as the patient or authorized representative, and then save your changes, download, and print, or share the form as needed.

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