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}