MLTC Policy 13.24:

Authorization for Release of Protected Health Information

  • Policy is also available in Portable Document Format (PDF)

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.24: Authorization for Release of Protected Health Information – Applicable to Partial MLTC, MAP, and PACE Plans

Date of Issuance: November 9, 2013

Effective upon release, all Partial MLTC, MAP, and PACE plans must use the OCA Official Form No. 960 for new enrollees when seeking authorization of the release of enrollee prospective enrollee) protected health information.

This policy does not impact consent forms currently on file for existing enrollees. Going forward, to ensure consistency across all MLTC plans and lessen potential provider confusion, plans should use the OCA Official Form No. 960 (instead of any alternative document currently in use). The form, which has been approved by the New York State Department of Health, is attached for your review and can be accessed online here.

MLTC plans should assist the individual in understanding the content of the form. The authorization must be signed and dated, and the enrollee must receive a signed copy. A copy must be maintained in the MLTC plan´s records


                    [This form has been approved by the New York State Department of Health]
Patient Name

Date of Birth Social Security Number
Patient Addreess

I, 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 of 1996 (HIPAA), I understand that:

1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the appropriate line in Item 9(a). 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 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.

2. If I am authorizing the release of HIV–related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization unless permitted to do so under federal or 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.

3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.

5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law.


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

8. Name and address of person(s) or category of person to whom this information will be sent:

9 (a). Specific information to be released:
          Medical Record from (insert date) ____________________________ to (insert date) ____________________________
          Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals,
               consults, billing records, insurance records, and records sent to you by other health care providers.
          Other: ____________________________                                                     Include: (Indicate by Initialing)
                          ____________________________                                                      _______________ Alcohol/Drug Treatment
                                                                                                                                                 _______________ Mental Health Information
                                                                                                                                                 _______________ HIV–Related Information
Authorization to Discuss Health Information
      (b) By initialing here ______________ I authorize ___________________________________________________________________
                                                          Initials                                                                 Name of individual health care provider
            to discuss my health information with my attorney, or a governmental agency, listed here:
                                                                                  (Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
              At request of individual
11. Date or event on which this authorization will expire:
12. If not the patient, name of person signing form:

13. Authority to sign on behalf of patient:

All items on this fonn have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.

____________________________________            Date: _______________________
Signature of patient or representative authorized by law.

* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonable could identify someone as having HIV symptoms or infection and information regarding a person´s contacts.

Instructions for the Use
of the HIPAA–compliant Authorization Form to
Release Health Information Needed for Litigation

This form is the product of a collaborative process between the New York State Office of Court Administration, representatives of the medical provider community in New York, and the bench and bar, designed to produce a standard official form that complies with the privacy requirements of the federal Health Insurance Portability and Accountability Act ("HIPAA") and its implementing regulations, to be used to authorize the release of health information needed for litigation in New York State courts. It can, however, be used more broadly than this and be used before litigation has been commenced, or whenever counsel would find it useful.

The goal was to produce a standard HIPAA–compliant official form to obviate the current disputes which often take place as to whether health information requests made in the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be noted, though, that the form is optional. This form may be filled out on line and downloaded to be signed by hand or downloaded and filled out entirely on paper.

When filing out Item 11, which requests the date or event when the authorization will expire, the person filling out the form may designate an event such as "at the conclusion of my court case" or provide a specific date amount of time, such as "3 years from this date".

If a patient seeks to authorize the release of his or her entire medical record, but only from a certain date, the first two boxes in section 9(a) should both be checked, and the relevant date inserted on the first line containing the first box.