AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION

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I HEREBY AUTHORIZE THE USE OR DISCLOSURE OF MY HEALTH
INFORMATION To : NAME ____________________________
ADDRESS___________________________
CITY STATE AND ZIP _________________
ATTENTION TO __________________________

THIS AUTHORIZATION APPLIES TO THE FOLLOWING INFORMATION:
? All records ? Lab ? Imaging Reports ? Immunizations
THE RECIPIENT MAY USE MY HEALTH INFORMATION ONLY FOR THE FOLLOWING PURPOSE
A SPECIFIC AUTHORIZATION IS REQUIRED TO RELEASE INFORMATION REGARDING
THE FOLLOWING: YES NO INITIALS ____________________ YES NO INITIALS _____________
HIV Information ? ? _______ /Drug/Alcohol Information ? ? _______
Mental Health Information ? ? _______.(YES NO INITIALS ______________)

The law prohibits the recipient from making further disclosure of your health information unless the recipient obtains another authorization from you or unless the disclosure is required or permitted by law. This authorization shall be valid until _________ Please indicate a date after which no information can be released. If no date is given, authorization is valid for 90 days only. I may refuse to sign this authorization and my refusal will not affect my ability to obtain treatment. I may revoke this authorization at any time, in writing. The revocation must be signed by me and sent to the Always Your Choice
The revocation is effective upon receipt but will have no impact on uses or disclosures made while the authorization was valid.

MUST COMPLETE FORM IN ORDER TO AVOID ANY DELAYS This authorization for use or disclosure of my health information is required by state and federal law.

Printed Patient Name ________________________ DOB:______
Daytime Telephone Number _______________________
Social Security No.: ___________________
I HAVE A RIGHT TO A COPY OF THIS AUTHORIZATION. Copy Requested: ? Yes ? No Copy Received: ? Yes ? No Patient Signature_________________

Witness __________________________________Date _________

ALLOWABLE CHARGE BY NYS LAW IS $ 0.75 PER PAGE. AMOUNT COLLECTED _____ DATE ________