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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
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
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-c- LLD gess, 1/4.,e_ Pigs 3 of 4 EFTA01650840 •HIPAA• OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health' Patient Name Date of Binh I or my authorized representative, request tha
authorized representative, request that health information regarding my cart and treatment be released asset forth on this form: In accordance with New York State Law and the Privacy Rule of the lkalth Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that: I. This authorization may inclu
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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
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
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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
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
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Mutual Connections (19)
Entities connected to both HIPAA and New York State Law
Medicaid
ORGANIZATION9 w/ HIPAA·4 w/ New
CA
Complete Address
PERSON3 w/ HIPAA·3 w/ New
Victim Services
ORGANIZATION3 w/ HIPAA·3 w/ New
First Hospital
ORGANIZATION3 w/ HIPAA·3 w/ New
the New York State Department of Health'
ORGANIZATION3 w/ HIPAA·3 w/ New
the Social Security Death Benefit
ORGANIZATION3 w/ HIPAA·3 w/ New
the New York City Commission of Human Rights
ORGANIZATION3 w/ HIPAA·3 w/ New
Disability Insurance
ORGANIZATION2 w/ HIPAA·2 w/ New
the Death Certificate
ORGANIZATION2 w/ HIPAA·2 w/ New
Primary Insurance Company
ORGANIZATION2 w/ HIPAA·2 w/ New
Governmental Agency Name
ORGANIZATION2 w/ HIPAA·2 w/ New
Albany
LOCATION2 w/ HIPAA·2 w/ New
The New York State Public Health Law
ORGANIZATION2 w/ HIPAA·2 w/ New
the State of New York
LOCATION2 w/ HIPAA·2 w/ New
Social Security Benefits
ORGANIZATION2 w/ HIPAA·2 w/ New
the New York State Division of Human Rights
ORGANIZATION2 w/ HIPAA·2 w/ New
See the Court Ordered Restitution Information
ORGANIZATION2 w/ HIPAA·2 w/ New
S. Swan
ORGANIZATION2 w/ HIPAA·2 w/ New
OVictim Assistance Program
ORGANIZATION2 w/ HIPAA·2 w/ New