Doh 5173-2026

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56 votes

The document is an authorization form from the New York State Department of Health's State Disability Review Unit, allowing patients or their representatives to request the release of health information for disability determination purposes. It outlines the patient's rights under HIPAA, including the types of information that can be disclosed, the process for revoking authorization, and instructions for completing the form. The form requires personal details and specifies which health records should be sent to assist in evaluating disability claims.

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Click ‘Get Form’ to open the doh 5173 in the editor.
Begin by entering your Patient Name, Date of Birth, and the last four digits of your Social Security Number in the designated fields.
Fill in your Address, Client ID Number (CIN), and Disability ID Number (DIN) as required.
In Section 7, provide the name and address of your healthcare provider who will send your health records.
Section 8 is pre-filled with the State Disability Review Unit’s information; ensure it is correct.
For Section 9(a), specify if you want records for a certain period or the entire medical record by checking the appropriate box.
If you wish to authorize discussions about your health information, initial in Section 9(b) and write the name of your healthcare provider.
Complete Sections 10 through 13 regarding the purpose of release and sign at the bottom to finalize your authorization.

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Versions	Form popularity	Fillable & printable
2016	4.9 Satisfied (56 Votes)

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5173

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