[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-307460-105":53,"doc-detail-307460-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","oca-form-960-fillable-health-information-authorization-hipaa","OCA-Form-960-fillable - Health Information Authorization (HIPAA)","","Health Information Authorization form for releasing a patient’s care and treatment records as specified. It explains when disclosure may include alcohol and drug abuse, mental health treatment (excluding psychotherapy notes), and confidential HIV-related information, with required initials. The form describes limits on redisclosure, the right to request recipients, nondiscrimination contact options, and the ability to revoke by written notice. It also states signing is voluntary, conditions are not affected, expiration details, and the parties allowed to discuss information.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/oca-form-960-fillable-health-information-authorization-hipaa/307460/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/oca-form-960-fillable-health-information-authorization-hipaa/307460.png","ImageObject",442,249,{"name":88,"@type":89},"\tWilliam","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":30},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What types of sensitive information require initials to authorize release?","Question",{"text":108,"@type":109},"Alcohol and drug abuse, mental health treatment (excluding psychotherapy notes), and confidential HIV-related information require the patient’s initials on the appropriate line in Item 9(a).","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Can the recipient redisclose HIV, alcohol/drug, or mental health information?",{"text":113,"@type":109},"No. The recipient is prohibited from redisclosing such information without the patient’s authorization unless permitted under federal or state law.",{"name":115,"@type":106,"acceptedAnswer":116},"How can the patient revoke this authorization?",{"text":117,"@type":109},"The patient may revoke at any time in writing to the health care provider listed on the form. Revocation does not apply to actions already taken based on the authorization.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},307460,1790557147,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4},5909887254083,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","| Patient Name   | Date of Birth   | Social Security Number  \u003Cbr>N/A   |\n| --- | --- | --- |\n|  |  |  |\n| Patient Address   |  |  |\n\nI,or my authorized representative,request that health information regarding my care and treatment be released as set forth on this form:In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of1996(HIPAA),I understand that:  \n1.This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE,MENTAL HEALTHTREATMENT,except psychotherapy notes,and CONFIDENTIALHIV*RELATED INFORMATION only ifIplace my initials onthe appropriate line in Item 9(a).In the event the health information described below includes any of these types of information,and Iinitial the line on the box in Item 9(a),I specifically authorize release of such information to the person(s)indicated in Item 8.  \n2.If I am authorizing the release of HIV-related,alcohol or drug treatment,or mental health treatment information,the recipient isprohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law.Iunderstand that I have the right to request a list of people who may receive or use my HIV-related information without authorization.IfI experience discrimination because of the release or disclosure of HIV-related information,I may contact the New York State Divisionof Human Rights at(212)480-2493 or the New York City Commission of Human Rights at(212)306-7450.These agencies areresponsible for protecting my rights.  \n3.I have the right to revoke this authorization at any time by writing to the health care provider listed below:I understand that I mayrevoke this authorization except to the extent that action has already been taken based on this authorization.  \n4.I understand that signing this authorization is voluntary.My treatment,payment,enrollment in a health plan,or eligibility forbenefits will not be conditioned upon my authorization of this disclosure.  \n5.Information disclosed under this authorization might be redisclosed by the recipient(except as noted above in Item 2),and thisredisclosure may no longer be protected by federal or state law.  \n6.THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL  \nCARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTALAGENCY SPECIFIED IN ITEM9(b).  \n\n| 7.Name and address of health provider or entity to release this information:   |  |\n| --- | --- |\n| 8.Name and address of person(s)or category of person to whom this information willbe sent:   |  |\n| 9(a).Specific information to be released:  \u003Cbr>Medical Record from (insert date)__     ___to(insert date)__  \u003Cbr>Entire Medical Record,including patient histories,office notes (except psychotherapy notes),test results,radiology studies,flms,  \u003Cbr>referrals,consults,billing records,insurance records,and records sent to you by other health care providers.  \u003Cbr>□Other:  \u003Cbr>Include:(Indicate by Initialing)  \u003Cbr>_____Alcohol/Drug Treatment  \u003Cbr>____Mental Health Information  \u003Cbr>_______HIV-Related Information  \u003Cbr>Authorization to Discuss Health Information  \u003Cbr>(b)□By initialing here_  \u003Cbr>nitiaITauthorize.  \u003Cbr>Name of individual health care provider  \u003Cbr>to discuss my health information with my attorney,or a governmental agency,listed here:  \u003Cbr>(Attorney/Firm Name or Governmental Agency Name)   |  |\n| 10.Reason for release of information:  \u003Cbr>At request of individual  \u003Cbr>Other:   | 11.Date or event on which this authorization will expire:   |\n| 12.If not the patient,name of person signing form:   | 13.Authority to sign on behalf of patient:   |\n\nAll tems on this form have been completed and my questions about this form have been answered.In addition,I have been provided a  \ncopy of the form.  \nDate:                   \nSignature of patient or representative authorized by law.  \n*Human Immunodeficiency Virus that causes AIDS.The New York State Public Health Law protects i","cbCailjsTfk4ayqo","https://ap.wps.com/l/cbCailjsTfk4ayqo","pdf",4116869,"English","# Patient and provider information\n## Release recipient details\n# Consent terms and restrictions\n## Sensitive information authorization\n## Redisclosure limitations and protections\n# Rights of the patient\n## Revocation and voluntary consent\n## Nondiscrimination contacts\n# Specific records to be released\n## Medical record scope and options\n# Expiration and signature\n## Expiration date and authority to sign","[{\"question\":\"What types of sensitive information require initials to authorize release?\",\"answer\":\"Alcohol and drug abuse, mental health treatment (excluding psychotherapy notes), and confidential HIV-related information require the patient’s initials on the appropriate line in Item 9(a).\"},{\"question\":\"Can the recipient redisclose HIV, alcohol/drug, or mental health information?\",\"answer\":\"No. The recipient is prohibited from redisclosing such information without the patient’s authorization unless permitted under federal or state law.\"},{\"question\":\"How can the patient revoke this authorization?\",\"answer\":\"The patient may revoke at any time in writing to the health care provider listed on the form. Revocation does not apply to actions already taken based on the authorization.\"}]","OCA-Form-960-fillable - Health Information Authorization (HIPAA) | PDF",1789849829]