(This form has been approved by the New York State Department of Health) 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient Name, Account Number, MR#, and Date in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the Patient Address and Telephone Number. This helps in contacting you regarding your health information.
4. In Item 6, specify the name and address of the health provider or entity that will release your information.
5. In Item 7, list the names and addresses of individuals to whom your information will be disclosed. You can add multiple entries as needed.
6. For Item 8, indicate what specific information you wish to disclose by checking the appropriate boxes. If applicable, initial next to Alcohol/Drug Treatment, Mental Health Information, or HIV-Related Information.
7. Complete Items 9 through 12 regarding the reason for release and authorization details. Make sure to sign and date at the bottom before submission.

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