Get New York State Hipaa Release Form 960

Filling out the New York State HIPAA Release Form 960 online is an important step in authorizing the release of personal health information. This guide provides clear, step-by-step instructions to help you complete the form accurately and confidently.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred browser.
2. Enter the patient name in the designated field. Ensure spelling is accurate for proper identification.
3. Input the date of birth of the patient. This information is critical for verifying identity.
4. Provide the patient's social security number in the appropriate section, using the format XXX-XX-____.
5. Fill out the patient's address in the specified field to help in communications regarding the health information release.
6. In item 9(a), indicate the specific information to be released by selecting the appropriate options, such as Medical Record or Entire Medical Record.
7. If applicable, initial the specific information sections related to Alcohol/Drug Treatment, Mental Health Information, or HIV-Related Information to authorize their release.
8. In item 9(b), you may authorize an individual healthcare provider to discuss the health information by initialing the designated area and entering their name.
9. State the reason for the release of information in item 10, generally indicating it is for eligibility verification with the New York State Office of Victim Services.
10. If you are completing the form on behalf of the patient, provide your name and authority to sign on their behalf in the dedicated section.
11. Specify the expiration date for the authorization in item 11, ensuring it aligns with the termination date for eligibility.
12. Sign and date the form in the designated area, confirming that you have completed all items and have had your questions answered. Ensure to keep a copy for your records.

Complete your documents online efficiently today!