Use this form to request a copy of your medical or dental records, or to authorize Hometown Health Centers to send your records to another provider. Print and complete the form, then either fax it to 518-395-9431 or drop it off at any Hometown reception desk.
What you type stays in your browser. Hometown does not receive or store anything you fill in here. Use the Print button to print a copy with your information, then bring or fax the printed form to us.
Authorization for Release of Health Information
Hometown Health Centers
Patient information
Patient Name
Date of Birth
Phone Number
Street Address
City
State
Zip Code
A. Authorize records FROM
Name
Address
City / State / Zip
Phone
Fax
B. To be released TO
Name
Address
City / State / Zip
Phone
Fax
C. Information disclosed (select one)
D. Special considerations
To include the following information, please initial below. If not initialed, this information will not be disclosed.
Alcohol / Drug treatment
HIV / AIDS-related information
Mental health treatment
Psychotherapy or SUD counseling notes
E. Purpose of requested information (select one)
F. Delivery method (select one)
G. Authorization expiration
Unless previously revoked by me in writing, this authorization will expire on the following date or event:
If left blank, this authorization will expire upon the completion of the release of information outlined in this document.
H. If not the patient
Print name of person signing authorization
I. Authority to sign on behalf of patient (authorized by law)
In accordance with New York State Law and the Privacy Rule of HIPAA (1996), I understand that:
This authorization may include disclosure of information relating to alcohol/drug treatment, mental health treatment (except psychotherapy notes), and HIV-related information only if I place my initials on the appropriate line in the Special Considerations section.
If I am authorizing the release of HIV-related, alcohol, drug-treatment, or mental-health information, the recipient is prohibited from re-disclosing it without my authorization unless permitted under federal or state law.
If I experience discrimination because of HIV-related disclosure, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450.
I have the right to revoke this authorization at any time by writing to the health care provider listed above (except where action has already been taken). Signing this authorization is voluntary; my treatment, payment, plan enrollment, or eligibility for benefits will not be conditioned on signing.
HHC reserves the right to charge the medical-record fee structure as set forth in NYS Article 18 Public Health Law.
Signature of patient or representative authorized by law · Print Name
Date
Witness statement
I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided.
Witness: staff signature, print name
Date