Email to [email protected]
*Asterisk fields must be completed
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
*Patient Name (Last Name, First Name) *Date of Birth
*Street Address *City *State *Zip Code
I, or my authorized representative, request that health information regarding my care and treatment is released as set forth on this form.
From: Optum Medical Care, P.C.
*Provider Name and Address:
Telephone Number:
*To: _______________________________________________
*
Name and Address:
_________________________________
__________________________________________________
*
Telephone
Number:
________________________________
Fax Number (for providers only): _____________________
*Specific information to be released:
Entire Medical Record from (insert date) to (insert date)
Specific Portions of the Medical Record as follows:
Other:
Check if granting authorization to discuss health
information
Include: (Indicate by Initialing)
________ HIV-Related Information*
Genetic Testing (inherited)
Reason for release of information:
At request of individual
Other:
*Date or event on which this authorization will expire:
This authorization will remain in full force and effect until I revoke
such authorization which I have agreed to do in writing.
(Indicate by initialing)
In accordance with applicable law, I understand that:
This authorization may
include disclosure of information relating to CONFIDENTIAL HIV* RELATED INFORMATION and/or GENETIC
TESTING only if I
place my initials on the appropriate line above. In the event the health information described above includes any of these types of information, and I
initial the line on
the box above, I specifically authorize release of such information to the person(s) indicated above.
If I am authorizing the release of HIV-related or genetic testing information, the recipient is prohibited from redisclosing such information without my
authorization unless permitted to do so under federal and state law. I
understand that I have the right to request a list of people who may receive or use my HIV-
related information without authorization.
If I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New
York State
Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies
are
responsible for protecting my rights.
I have the right to revoke this authorization at any time by writing to the health care provider listed above. I understand that I may
revoke this authorization
except to
the extent that action has already been taken based on this authorization.
I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits
will not b
e conditioned upon
my 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.
I understand that there is
a fee o
f
up to $0.75
/ page for copies of paper records that are not being sent to another health care provider based on NYS Public Health Law 18.
If not the patient, name o
f
person signing form:
Authority t
o
sign o
n behalf of patient:
Signature of patient or representative authorized
by law. By typing my name I authorize the disclosure outlined above.
I understand that typing my name is the legal equivalent of a handwritten signature
Date:
___________________
_____________
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of this form.
*Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify
someone as having HIV symptoms or infection and information regarding a person's contacts.
Rev 9/9/22
*if sending form by email, I consent to use of unencrypted email
I understand that I am sending an unencrypted email message to Optum. I acknowledge and understand that unencrypted email messages are not protected, and that there is a risk
of a violation of my privacy, which may include my personally identifiable health information being accessed or viewed by an unintended third party while in transit or when
stored on an electronic device, or by hacking or some other means.
I acknowledge that email messages may be inadvertently sent to the wrong email address and may be subject to technical malfunctions. Therefore, I understand that email message
delivery is not guaranteed. I understand and acknowledge that Optum has no responsibility for the content of my email if I happen to misplace my device, if someone views my
email messages, or if my device is stolen. I understand that the email messages will be delivered across the networks of various third parties (such as Apple, Verizon, Sprint, etc.),
and Optum makes no representations or warranties regarding the quality, reliability, timeliness or security of such third party networks, or their services or equipment.
Despite the risks, I am authorizing Optum to communicate with me via email, including by exchanging personally identifiable health information.
I understand that I am responsible for notifying Optum in writing if I choose to discontinue email communications or if my email address changes.
