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

Page 3 of 4 EFTA01650819 •RIPAA' OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION 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 inc

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

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 IIIIPAA I understand that I This authorization may include

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

y authorized representative, request that h h 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 inclu