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Click ‘Get Form’ to open it in the editor.
Begin by filling in your personal information in Section 1. Include your name, date of birth, student/employee ID number, and contact details.
In Section 2, specify the names and addresses of the individuals or entities that will receive your health information.
For Section 3, select the reason for disclosing your information from the provided options. If 'Other' is selected, please specify.
In Section 4, check all applicable types of information you wish to disclose. Be sure to include relevant dates where necessary.
Finally, complete Section 5 by indicating how long this authorization will remain valid. Choose from the options provided or specify an event.

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How do I contact NYU?

Academic Resource Center. (212) 998-2272. Bookstore and Technology Store. (212) 998-4667. Bursar. (212) 998-2806. Center for Student Life. (212) 998-4411. Center for Multicultural Education and Programs. (212) 998-4343. Dining Services. (212) 998-4900. Financial Aid. (212) 998-4444. Office of Global Services. (212) 998-4720.

What is a release of information form?

A Release of Information (ROI) is a document that allows a client to choose what information is released from their medical record. It also allows the client to choose who receives the information, how long it can be released, and under what guidelines.