HipaaRelease001

Authorization for Release & Exchange of Health Information Pursuant to HIPAA
Request Type [Internal Use Only]
Overide Value
What is the main goal of your records request?*

For East End Mental Health to receive health records.For East End Mental Health to send health records.For East End Mental Health to be able to communicate with providers.
What is the reason for this request?*

Transition of CareCoordination of CareOther
How would you like these records sent?*

By FaxBy Mail

PATIENT INFORMATION
First Name*
MI
Last Name*
Date of Birth*
MM/DD/YYYY
Phone Number*
Please enter a valid phone number.
Age
Email Address*
example@example.com
Address Line 1*
Address Line 2
City*
State*
Zip Code*

PARENT/GUARDIAN INFORMATION
Full Name of Parent/Guardian Executing this Authorization*

First NameMiddle InitialLast Name

PERSON TO SEND RECORDS
PERSON TO RECEIVE RECORDS
PERSON TO COMMUNICATE WITH
Name of Person/Entity*
Phone Number of Person/Entity*
Please enter a valid fax number.
Fax Number of Person/Entity*
Please enter a valid fax number.
Address Line 1*
Must Be Accurate & Complete
Address Line 2
City*
State*
Zip Code*

SCANNED/FAXED REQUEST UPLOAD
Upload Request*

Cancelof

OFFICE COMMENTS
Office Comments

FEES FOR HEALTH RECORDS
Our practice does charge for health record requests a fee of $0.75 per page pursuant to NY Pub Health Law Chapter 45 Article 1, Title 2, §17.

However when a patient requests that we send a health record in order to transition care or coordinate care; our office will waive the fee when sending only the intake note, most recent progress note, medication chart, and the most recent lab results that we have ordered if applicable.
Please confirm that you have been advised of the fees.*

I understand and wish to continue with my request.

SPECIFIC INFORMATION TO BE SENT
What information with in the health record are you requesting to be sent. Please select all that apply.*

The entire health recordThe entire health record within a specific date rangeThe intake noteMost recent psychiatric progress noteMedication chartMost recent laboratory results ordered by East End Mental HealthOther
You have indicated that you would like "the entire record within a specific date range" to be sent. Please send the date range below.
Start Date*

MonthDayYear
Date
End Date*

MonthDayYear
Date

PROCESSING TIME OF REQUESTS
Federal statute allows for processing times of health record requests to be up to 30 calendar days after receipt of the request pursuant to Title 45 of Public Welfare Law § 164.524.

However we make all efforts to process health records in 7 to 14 calendar days based upon the number of requests we receive.
Please confirm that you have been advised of the processing time.*

I understand and wish to continue with my request.

IDENTITY VERIFICATION
Please Upload a Copy of the Front of Your Photo ID.*

Your Photo ID may be either a State Issued Drivers License, State Issued Driver's Learner Permit, State Issued Non-Driver ID Card, or Passport with Photo ID. No other forms will be accepted.
Cancelof

Authorization for Release & Exchange of Health Information Pursuant to HIPAA

Patient Information

Patient:	{firstName} {mi} {lastName}
Date of Birth:	{dateOf}
Address:	{addressLine} {addressLine110} {city}, {state} {zipCode}

This authorization includes the disclosure of the patient's health record including information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION. The patient understands that the patient has the right to request a list of people who may receive or use my HIV-related information without authorization. If the patient experiences discrimination because of the release or disclosure of HIV-related information, the patient may contact the New York State Division of Human Rights at 1 (212) 480- 2493 or the New York City Commission of Human Rights at 1 (212) 306-7450. These agencies are responsible for protecting patient rights. Patients have the right to revoke this authorization at any time by writing to the East End Mental Health at 332 West Montauk Highway Suite 5 Hampton Bays, New York 11946. The patient understands that the patient may revoke this authorization except to the extent that action has already been taken based on this authorization. The patient understands that agreeing to this authorization is voluntary. The patient's treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon the patient's authorization of this disclosure. Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by federal or state law (with exception to HIV-related information). THIS AUTHORIZATION DOES NOT AUTHORIZE EAST END MENTAL HEALTH TO DISCUSS THE PATIENT'S HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE PARTY EXPRESSLY AGREED UPON.

Name and address of health provider or entity to release and exchange this information:

{nameOf27} {addressLine120}{addressLine121} {city122}, {state124} {zipCode123} {phoneNumber}

I agree to the Terms & Conditions of Authorization Pursuant to HIPAA
Signature*

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Date*

MonthDayYear
Date
332 W Montauk Hwy Suite 5 Hampton Bays, NY 11946 P 631.495.3300 F 631.822.2833 eastendmentalhealth.com
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Authorization for Release & Exchange of Health Information Pursuant to HIPAA

PATIENT INFORMATION

PARENT/GUARDIAN INFORMATION

PERSON TO SEND RECORDS

PERSON TO RECEIVE RECORDS

PERSON TO COMMUNICATE WITH

SCANNED/FAXED REQUEST UPLOAD

OFFICE COMMENTS

FEES FOR HEALTH RECORDS

SPECIFIC INFORMATION TO BE SENT

PROCESSING TIME OF REQUESTS

IDENTITY VERIFICATION

Authorization for Release & Exchange of Health Information Pursuant to HIPAA