![]() ![]() It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counse l would find it useful. This form is the product of a collaborative process between the New York State Office of Court Administratio n, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act (“HIPAA”) a nd its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. Instructions for the Use of the HIPAA - compliant Authorization Form to Release Health Information Needed for Litigation Name and address of health provider or entity to release this information: * THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 ( b Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2 ), and this redisclosure may no longer be protected by federal or state law.Ħ. ![]() My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.ĥ. I understand that signing this authorization is voluntar y. ![]() I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.Ĥ. I have the right to revoke this authorization at a ny time by writing to the health care provider listed below. These agencies are responsible for protecting my rights.ģ. ![]() If I experience discrimination because of the release or disclosure of HIV - related information, I may contact the New York State Division of Human Rights at (212) 480 - 2493 or the New York City Commission of Human Rights at (212) 306 - 7450. I understand that I have the right to request a list of people who may receive or use my HIV - related information without authorization. If I am authorizing the release of HIV - related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so unde r federal or state law. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initial s on the appropriate line in Item 9(a In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) i ndicated in Item 8. I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:ġ. ![]()
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