NYCPG Consent to ROI

Release of Information Form
AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION
(Patient’s Name)*
Address*
(Date of Birth)*

MonthDayYear
Date
do hereby authorize*
contained in my medical records (except psychotherapy notes) created by provider named above to the individual(s) or organization(s) listed below for the purposes of assessment, treatment, information management, and payment services related to participation in the Problem Gambling Resource Center
1. Name and Address of person(s) or organization(s) to whom disclosure is to be made:
New York Council on Problem Gambling
New York State Office of Addiction Services and Supports
The recipient is prohibited from re-disclosing these records without my authorization unless permitted to do so under State or Federal law.
This Authorization for the Release of Confidential Information shall become effective on the date of execution of my signature hereinafter, and this Authorization, which grants specific authority for the release of protected health information by Clinician Name, shall remain valid until (Date) for one calendar yearupon which date this Authorization shall automatically expire. I retain the right to revoke this Authorization at any time by providing a written notice to Clinician Name, but I understand and agree that my consent to release information shall remain in effect until the date the revocation is date stamped in by the Medical Records Department, and any documents released previous to that date are considered to be authorized and approved by me. I also understand that any disclosure/release must comply with New York State law and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”); and that re-disclosure of this information to a party other than the one designated above is forbidden without additional written authorization on my part.*

MonthDayYear
Date
Signature of Client or Participant

Clear
Printed Name of Client or Participant*
Signature of Representative (if applicable)

Clear
Printed Name of Client or Participant
Printed Name of Representative (if applicable)
Executed this ___ day of _______ 20___*

DayMonthYear
Date
Should be Empty:

Release of Information Form

AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION