REASONABLE ACCOMMODATION REQUEST FORM
INSTRUCTIONS: Clients must complete Section I and submit this form along with any supporting
documentation to the Program/Facility Director, or functional equivalent (“Director”). DHS and provider
staff must offer to help the client with completing this form.
Section I: (This section must be completed by or with the client.)
Name: __________________________________________________________________________
Facility/Program: __________________________________________________________________
Client ID/SSN: _______________________________ Phone: ______________________________
Describe the Accommodation Requested (attach any supporting documentation).
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Section II Instructions: Any Director receiving a completed form with disability-related documentation
must complete Section II, return a copy to the client, and immediately transmit by email or fax the
request and supporting documents to the appropriate Program Administrator. Supporting
documentation is not required if the disability is obvious/apparent or otherwise known to DHS.
Section II: (To be completed by the Facility Director or designee.)
Name/Title: ______________________________________________________________________
Facility/Program: __________________________________________________________________
Address: ________________________________________________________________________
Phone: ___________________________ Date Received: _________________________________
I discussed the HIPAA form with the client and the client consented to complete a HIPAA form.
I discussed the HIPAA form with the client and the client declined to complete a HIPAA form.
Signature: _______________________________________________________________________
After completing, provide a copy of this form to the client.
(Turn Page)
DHS-13 (E) 08/04/2022 (page 1 of 3) LLF
DHS-13 (E) 08/04/2022 (page 2 of 3) Department of Social Services
LLF Department of Homeless Services
HIPAA AUTHORIZATION FOR THE DISCLOSURE
OF INDIVIDUAL HEALTH INFORMATION
I, or my authorized representative, request that health information about my medical care and
treatment be released as outlined below. Federal and state law and regulations, including the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) safeguard the privacy of my
protected health information (collectively “health records”).
Before signing, I understand that:
1. My health records may include confidential ALCOHOL and DRUG ABUSE, MENTAL
HEALTH TREATMENT (except psychotherapy notes), and HIV-RELATED
1
INFORMATION. This information will only be released if I sign my initials in the appropriate
boxes in Item 8(a).
2. I can ask for a list of people who may get or use my HIV-related information without my
consent. If I suffer discrimination because of the release 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 on Human Rights at (212) 306-7450. They are in charge of protecting my
rights.
3. Signing this form is voluntary. If I do not sign it, my treatment, payment to treatment
providers, enrollment in a health plan, and eligibility for shelter will not be affected.
But, if I do not sign it and I did not submit documentation with my reasonable
accommodation request, my reasonable accommodation request may be denied
because the NYC Department of Homeless Services (DHS) did not have any
supporting documentation or information to review.
4. I can change my mind at any time except for any information that has already been
released. To do so, I must tell my shelter or facility director in writing.
5. My health information shared under this consent may be re-released by DHS. The privacy
of this information may no longer be protected by federal or state law.
(Turn Page)
1
Human Immunodeficiency Virus causes AIDS. The New York State Public Health Law protects information which
reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
Client Name
Date of Birth
Case ID Number
Last 4 digits of Social Security Number
DHS-13 (E) 08/04/2022 (page 3 of 3) Department of Social Services
LLF Department of Homeless Services
6. Name and address of health provider or entity to release this information:
7. This health provider will send this information to: NYC Department of Social Services,
Customized Assistance Services, Office of Reasonable Accommodations, 150
Greenwich Street, 30th floor, New York, NY 10007.
8(a). 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
8(b). By initialing here _______________, I allow ____________________________________
(Initials) (Name of individual health care provider)
to discuss my health information with the NYC Department of Social Services.
9. Reason for release of information: At request of Patient for purpose of reasonable
accommodation request only.
10. Expiration date: One year from the date of signature
All items on this form have been completed and my questions about this form have been answered.
I was given a copy of the form
Signature of Patient or Authorized Representative by Law
Date
If not the Patient, name if individual signing form
Authority to sign on behalf of patient
The best phone number to contact me
PERMISSION TO SHARE HEALTH INFORMATION
FLY-1052 (E)
06/15/2020
INFORMATION ABOUT THE HEALTH
INSURANCE PORTABILITY AND
ACCOUNTABILITY (HIPAA)
CONSENT FORM
This FAQ helps
explain the HIPAA consent form and
why we are asking you to complete it.
Why should I complete the HIPAA consent form?
Some Reasonable Accommodation Requests (RAR) need a review to decide if it
will be approved. The Office of Reasonable Accommodations (ORA) reviews
relevant information from your provider to make this determination. Signing the
HIPAA consent lets ORA contact your provider when more information is needed to
decide about your request. Signing it saves time in the review process.
What information will be collected using this form?
ORA will only ask for information related to the Reasonable Accommodation (RA)
that you asked for. Staff will not use the form to contact your provider to get any
information unrelated to your request.
How do I complete this form?
• You must fill out, sign, and date the HIPAA consent for it to be valid.
• The HIPAA consent is valid for one year from the date you sign it.
• If you are not able to sign the consent, an authorized representative can sign
for you. If an authorized representative is signing for you, you must give us a
document that proves their authority, such as a Power of Attorney or
Guardianship Commission.
(Turn page)
FLY-1052 (E)
06/15/2020
INFORMATION ABOUT THE HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY (HIPAA) CONSENT FORM (continued)
What if I no longer want ORA to use this form to reach out to my provider?
You can tell us to stop the use of the form at any time, but you must tell the shelter
or facility director in writing.
Note: You don’t need to sign this consent if you don’t want our help getting
information from your provider. Instead, you can get relevant information directly
from your providers to hand in with your accommodation request.
What if I don’t have any documentation?
If you do not have any documentation to submit with the RAR(s), and you do not
complete and sign the HIPAA form, your request may be denied because we did not
have any supporting documents or information to review.
What if I have more questions about this form?
DHS staff and shelter staff will answer any questions you have about the form and
can help you fill it out in person.
