Omh information 2026

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The document is a form from the New York State Office of Mental Health that serves as an authorization for the release of a patient's protected health information. It requires completion by the patient or their representative, detailing the information to be disclosed, the purpose of disclosure, and the parties involved. The form emphasizes confidentiality under federal and state laws, outlines the patient's rights regarding revocation and inspection of their information, and includes sections for signatures and witness statements.

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Click ‘Get Form’ to open the omh information document in the editor.
Begin by entering the Patient’s Name (Last, First, M.I.) and ‘C’ No. in the designated fields at the top of the form.
Fill in the Date of Birth and Sex fields accurately to ensure proper identification.
In Part 1, specify the Description of Information to be Used/Disclosed and provide a clear Purpose or Need for Information by selecting the appropriate options.
Complete the sections for both 'From' and 'To' by entering the Name, Address, & Title of both parties involved in the disclosure.
Review all entries for accuracy before signing. Ensure that you understand your rights regarding this authorization as outlined in the document.
Finally, sign and date where indicated, ensuring that any Personal Representative also provides their details if applicable.

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