Fillable Authorization for Release of Health Information

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Authorization for Release of Health Information

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VD001 (6/11/19)
Page 1 of 2
Authorization for Release of Health Information
Patient Name (Print) Date of Birth
Patient Address (Print and include Apt#) Telephone Number
E-mail Address
1. Contact information of health care provider or entity to release this information:
Name: Address:
Phone #:
2a. Contact information of person(s) or entities who will receive this information:
Name: Address:
Phone #: Fax: E-mail:
2b. Method of delivery for release of information:
£ Pick-up at facility £ Mail £ Fax £ USB Flash Drive £ E-mail (to have sent by unencrypted E-mail complete page 3)
£ V
erbal ______ PLEASE INITIAL HERE to authorize the person or a representative from the entity specified in Section 1 to discuss the
health information being released under this Authorization with the person, or representative from the entity, specified in Section 2. I
understand that if this Authorization covers laboratory testing results, the laboratory CANNOT answer any questions in reference to
interpretation, diagnosis or treatment of these results. Please address all questions with the PATIENT’S PHYSICIAN ONLY.
£ Other method of delivery (please explain): ______________________________________________________________________________
3a. Specific information to be released:
£ Medical Record Abstract (summary of record)
£ Medical Record from (insert date) ____________________ to (insert date) ____________________
£ Entire Medical Record
£ Laboratory results for date of service ____________________
£ Other: ____________________________________________________________________________________________________________
3b. The following types of information will NOT be released unless you or your authorized representative initial in the appropriate spaces provided
below:
 ____ Substance Abuse Treatment Information (including diagnostic information, medications and dosages, lab tests, allergies, substance use
history summaries, trauma history summary, employment information, living situation and social supports, and claims/encounter data)
 ____ Mental Health Treatment Information
 ____ HIV-Related Information
4. Reason for release of information:
£ At request of individual £ Other: _______________________________________________________________________________________
Copy 1 – Patient Medical Record
Copy 2 – Patient or Patient’s Personal Representative
Authorization for Release of Health Information
VD001 (6/11/19)
Page 2 of 2
Copy 1 – Patient Medical Record
Copy 2 – Patient or Patient’s Personal Representative
*The signature of the patient must be obtained unless the patient is an unemancipated minor under the age of 18 or lacks capacity to make medical
decisions. In these cases the Agent, Surrogate or Guardian should sign.
Only for use when interpreter services are utilized for the completion of this form:
_______________________________________________________
Telephonic Interpreter’s ID # Date/Time
OR
_______________________________________________________ _______________________________________________________
Signature: Interpreter Date/Time Print: Interpreter’s Name and Relationship to Patient
_______________________________________________________ _______________________________________________________
Witness to Signature Print Witness Name
***Patients requesting information by unencrypted E-mail must complete “Permission to Send Information Requested by Unencrypted
E-mail” (Form# VD001E).
5. I, or my authorized representative, request that health information regarding my care and treatment be accessed, used and/or disclosed as
stated on this form. In accordance with New York State Law, 42 CFR Part 2 and the Privacy Rule of the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), I understand that:
 a. I have the right to revoke this Authorization and my Permission to Send Information Requested by Unencrypted E-mail (page 3 of this
document) at any time by writing to the health care provider listed in Section 1. I understand that I may revoke this Authorization except to
the extent that action has already been taken in reliance on this Authorization.
 b. I understand that signing this Authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not
be conditioned upon my authorization of this disclosure.
 c. Information disclosed under this Authorization might be redisclosed by the recipient, and this redisclosure may no longer be protected by
federal or state law. However, if I am authorizing the release of substance abuse treatment, mental health treatment, or HIV-related
information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or
state law.
6. Date or event on which this Authorization will expire (this field must be completed with a date or event):
7. Patient/Agent/Surrogate/Guardian* (Signature): 8. Date:
9. Printed name of person signing this form: 10. Authority to sign on behalf of patient or relationship to patient
(if applicable):
Permission to Send Information Requested by Unencrypted E-mail
VD001E (6/11/19)
Page 1 of 1
If you are requesting health information (pursuant to the attached Authorization Form# VD001) be released via unencrypted E-mail, Northwell
Health asks that you acknowledge and consent to the following:
Unless I request otherwise, E-mails containing health information sent to me from Northwell Health are encrypted to keep them secure during
transmission. I understand that most personal E-mail services do not encrypt or otherwise protect E-mails and, therefore, I understand that E-mail
sent unencrypted means others may be able to access the information and read it once it is transmitted over the Internet. Despite this risk, I
authorize my provider to transmit the information I have requested by unencrypted E-mail.
I further acknowledge that E-mails may be inadvertently sent to the wrong address and may be subject to technical malfunctions. Therefore, I
understand that E-mail delivery is not guaranteed and potentially subject to unauthorized disclosure to third parties.
*The signature of the patient must be obtained unless the patient is an unemancipated minor under the age of 18 or lacks capacity to make medical
decisions. In these cases the Agent, Surrogate or Guardian should sign.
Only for use when interpreter services are utilized for the completion of this form:
_______________________________________________________
Telephonic Interpreter’s ID # Date/Time
OR
_______________________________________________________ _______________________________________________________
Signature: Interpreter Date/Time Print: Interpreter’s Name and Relationship to Patient
_______________________________________________________ _______________________________________________________
Witness to Signature Print Witness Name
**For consent regarding on-going electronic communications not related to the release of medical records, please use the “Northwell Health
Consent to E-mail and Text Communications” (Form# VD032).
Patient/Agent/Surrogate/Guardian* (Signature): Date:
Printed name of person signing this form: Authority to sign on behalf of patient or relationship to patient (if
applicable):
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Authorization for Release of Health Information

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Completed 9 November 2021

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