Bridging the justice gap in New York

AUTHORIZATION FOR RELEASE

OF CONFIDENTIAL INFORMATION

I,                                              , hereby authorize you, the Department of Correctional Services (DOCS), to release my medical and dental records, including any records that may contain confidential HIV (Human Immunodeficiency Virus that can cause AIDS) related information to                                                 , and his/her/its medical experts and/or consultants who may evaluate my records.

I also authorize                                      and his/her/its medical experts and/or consultants to release information they acquire from my medical and/or dental records to DOCS and other health care providers and their respective legal representatives.

I authorize the release of this confidential HIV-related information solely for the purposes of legal representation, securing medical care and/or improving conditions of my confinement.  A photocopy of this Release should be honored.  This Release is effective for one year from the date signed below.

I understand that confidential HIV-related information is any information indicating that a person had an HIV-related test, or has an HIV infection, HIV-related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.  Under New York State Law, Public Health Law Article 27 F, with specific exceptions, confidential HIV-related information can only be given to persons I allow to have it by signing :a release.  I can ask for a list of people who are the exception to this rule, i.e., those people who can obtain this information without my authorization.  I also understand that beyond the disclosure that I have expressly authorized, or that is otherwise permitted by law, no further disclosure of this information should be made.

I understand that I do not have to sign this form and that I can revoke my consent to the release of HIV-related information at any time.  I do not have any further questions about this form or what I am authorizing to be released and to whom.  I have read all of the above before signing this authorization form.

Date:                                                                Signature:                                                                    

DOCS’ ID Number:                                         Birth Date:                                                                   

Form based on information provided by Prisoners’ Legal Services of New York