The releasor authorizes his/her employer to release employment references including, but limited to, his/her employment history and wages and any information which may be requested relative to his/her employment, employment applications, and other related matters, and to furnish copies of any and all records which the employer may have regarding his/her employment.
Release Of Information Form Mental Health In Queens
Category:
State:
Multi-State
County:
Queens
Control #:
US-00458
Format:
Word;
Rich Text
Instant download
Description
Form popularity
FAQ
Release of Information Authorization Under the HIPAA Privacy Rule, when a release of information is intended for purposes other than medical treatment, healthcare operations, or payment, you'll need to sign an authorization for ROI.
Covered entities (anyone providing treatment, payment, and operations in healthcare) and business associates (anyone who has access to patient information and provides support in treatment, payment, or operations) must meet HIPAA Compliance.
You can also visit the NYC Department of Health's Chelsea Van, located near Chelsea Clinic at 9th Avenue and 28th street, to complete an Authorization for Release of Health Information form and give it to staff on site. Call 311 or 212-NEW-YORK (212-639-9675) for help.
A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.
HIPAA is the federal Health Insurance Portability and Accountability Act of 1996. The primary goal of the law is to make it easier for people to keep health insurance, protect the confidentiality and security of healthcare information and help the healthcare industry control administrative costs.
An individual's personal representative (generally, a person with authority under State law to make health care decisions for the individual) also has the right to access PHI about the individual in a designated record set (as well as to direct the covered entity to transmit a copy of the PHI to a designated person or ...
Authorization. A covered entity must obtain the individual's written authorization for any use or disclosure of protected health information that is not for treatment, payment or health care operations or otherwise permitted or required by the Privacy Rule.
I hereby authorize use or disclosure of protected health information about me as described below. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it, and would then no longer be protected by federal privacy regulations.
To request a copy of a medical record from a hospital, call or write to the hospital holding the record. You must speak to the Medical Records Department and request a release of medical information authorization form from the hospital.
Obtaining Copies of your Medical Record You may click on the "Authorization for Use and Disclosure of Patient Information" form found below. Please complete the form and fax it to our department to obtain copies of your medical records.
