Authorization for Release of Health Information - Including Alcohol/Drug Treatment, Mental Health Information and Confidential HIV/AIDS Related Information

Sep 17, 2026

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Authorization for Release of Health Information requests disclosure of an individual’s medical care and treatment records as specified on the form. It explains that the authorization may cover alcohol and drug treatment, mental health treatment, and confidential HIV/AIDS related information only when initialed in item 8, and describes limits on re-disclosure and use without further authorization. The form states rights to revoke, voluntariness, and conditions affecting treatment. It also provides sections for provider and recipient details, purpose, covered dates, signature, and witness confirmation.

LanguageEnglish

CategoryLetters

FormatPDF

Pages1

AccessFree to download

Authorization Sections

Patient and Request Statement

Understanding and Legal Protections

Revocation and Voluntary Consent

Provider/Recipient Details and Purpose

Specific Information Covered and Initials

Signature and Witness Statement

Authorization for Release of Health Information (Including Alcohol/Drug Treatment NEW YORK STATE DEPARTMENT OF HEALTH and Mental Health Information) and Confidential HIV/AIDS related Information | Patient Name | Date of Birth | Patient Identification Number | | --- | --- | --- | | Patient Address | | | I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that: 1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL HIV/AIDS RELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6. 2. With some exceptions, health information once disclosed may be re disclosed by the recipient. If I am authorizing the release of HIV/AIDS related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re disclosing such information or using the disclosed information for anyother purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS related information, I may contact the New York State Division of Human Rights at 1 888 392 3644. This agency is responsible for protecting my rights. 3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization. 4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent. | 5. Name and Address of Provider or Entity to Release this Information: | | | | | | --- | --- | --- | --- | --- | | 6. Name and Address of Person(s) to Whom this Information Will Be Disclosed: | | | | | | 7. Purpose for Release of Information: | | | | | | 8. Unless previously revoked by me, the specific information below may be disclosed from: INSERT START DATE until INSERT EXPIRATION DATE OR EVENT All health information (written and oral), except: | | | | | | For the following to be included, indicate the specific information to be disclosed and initial below.
Records from alcohol/drug treatment programs |
Information to be Disclosed Initials | | | | | Clinical records from mental health programs* | | | | | | HIV/AIDS related Information | | | | | | 9. If not the patient, name of person signing form: | | | 10. Authority to sign on behalf of patient: | | All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form. SIGNATURE OF PATIENT OR REPRESENTATIVE AUTHORIZED BY LAW DATE Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient’s authorized representative. | STAFF PERSON’S NAME AND TITLE | SIGNATURE | DATE | | --- | --- | --- | This form may be used in place of DOH 2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Abuse Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatment related information or confidential HIV related information released through this form must be accompanied by the require

FAQs

What information can be released under this authorization?

The form authorizes release of health information regarding care and treatment as set forth on the document. Coverage of alcohol/drug treatment, mental health treatment, and confidential HIV/AIDS related information requires initials in item 8.

Can the recipient re-disclose the information?

With some exceptions, once disclosed the recipient may re-disclose health information. If the authorization covers HIV/AIDS related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from re-disclosing or using it for other purposes without authorization unless allowed by federal or state law.

How can the patient revoke this authorization?

The patient may revoke the authorization at any time by writing to the provider listed in item 5. Revocation applies except to the extent that actions have already been taken based on the authorization.

Sep 17, 2026

Upload by Patrick