HRA-108 (E) 03/14/2018 (page 1 of 2) LLF
HIPAA AUTHORIZATION FOR THE DISCLOSURE
OF INDIVIDUAL HEALTH INFORMATION
Patient Name:
Social Security Number:
Patient Address:
Date of Birth:
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 Article 27-F of the New York State Public Health
Law, the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and
42 U.S.C. § 290dd-2 and its implementing regulations at 42 C.F.R. Part 2, I understand that:
1. 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 initials on the appropriate
line in Item 10(b). 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 10(b), I specifically authorize
release of such information indicated in Item 10(b) to the NYC Human Resources
Administration (HRA).
2. In the event that HRA determines that I am potentially eligible for federal disability benefits, I
authorize HRA to release my medical and/or mental health treatment information, which may
include confidential HIV related information and/or alcohol or drug treatment records to the
Social Security Administration (SSA) for its review of my eligibility for federal disability
benefits.
3. 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 experience discrimination because of the release
or disclosure of HIV-related information, I may contact the New York State Division of Human
Rights at 212-961-8650 or the New York City Commission of Human Rights at 212-306-7450.
These agencies are responsible for protecting my rights.
4. I understand that signing this authorization is voluntary. My treatment, payment to treatment
providers, enrollment in a health plan, or eligibility for benefits will not be conditioned upon
my authorization of this disclosure. However, if I do not authorize HRA to share my medical
information with SSA, this may result in a discontinuance of my Cash Assistance (CA)
benefits.
Human Immunodeficiency Virus causes AIDS. The New York State Public Health Law
protects information which reasonably could identify someone as having HIV symptoms,
infection, or AIDS, or that reasonably could identify someone who may have been exposed
to HIV or AIDS through contact with a protected individual.
(Turn Page)
HRA-108 (E) 03/14/2018 (page 2 of 2) Human Resources Administration
LLF Family Independence Administration
5. I understand that I may revoke this authorization except to the extent that HRA and my
medical provider have already acted upon it. I may revoke this authorization at any time by
writing to the health care provider at the address specified below and to HRA at:
NYC Human Resources Administration, Office of Constituent Services, 150 Greenwich
Street, 35th Floor
, New York, NY 10007.
6. Authorized recipients of my medical information may, in certain instances, have the right to
redisclose my medical documentation without the need to obtain additional written consent
from me. I understand that such redisclosures may no longer be protected by federal or
state law.
7. This authorization does not authorize my medical provider to discuss my health
information or medical case with anyone
other than the NYC Human Resources
Administration as specified in item 10(b).
AUTHORIZATION TO DISCUSS HEALTH INFORMATION
8. Name and address of health provider or entity to release this information: _______________
__________________________________________________________________________
9. Name and address of agency to whom this information will be sent:
NYC Human Resources
Administration,
Customized Assistance Services, Office of Reasonable
Accommodations, 150 Greenwich Street, 30th floor, New York, NY 10007
10(a). Specific information to be released: Medical records for the entire year prior to the
signature date below.
Include (Indicate by Initialing):
Alcohol/Drug Treatment Mental Health Information HIV Related Information
10(b). By initialing here __________, I authorize ________________________________________
(Initials) (Name of individual health care provider)
to discuss my health information with the NYC Human Resources Administration.
11. Reason for release of information: At request of patient
12. Date or event on which this authorization will expire: One year from the date of signature
13. If not the patient, name of person signing form: ___________________________________
14. Authority to sign on behalf of patient: ___________________________________________
All items on this form have been completed and my questions about this form have been answered.
In addition, I have been provided with a copy of the form.
Signature
of Patient or Authorized Representative by Law
Date
