Epstein Secrets

ion 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

ION PURSUANT TO HIP In accordance with New York State Law and the Privacy Rule of the I lealth 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, exce

tion 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

s. (Keep a copy for your records.) • All bills and receipts for sennces listed on this form • Your completed, signed claim form • One completed HIPAA farm for each service provider listed on this form (You can photocopy the HIPAA form ) • Letters from any insurers denying or authorizing payment f

ation because of the release or disclosure of WV-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

Ot:A Official Form No.: 960 H1PAA• AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' I, or my authorized representative, request that h h information regardin