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Scan 0051

Scan 0051

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Published by Alec Stais

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Published by: Alec Stais on Jan 10, 2012
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01/10/2012

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AuthorizationforReleaseofConfidentialHIV*RelatedInformationNewYorkStateDepartmentofHealthAIDSInstitute
ConfidentialHIVrelatedinformationisanyinformationindicatingthatapersonhadanHIVrelatedtest,orhasHIVinfection,HIVrelatedillnessorAIDS,oranyinformationwhichcouldindicatethatapersonhasbeenpotentiallyexposedtoHIV.UnderNewYorkStateLaw,confidentialHIVrelatedinformationcanonlybegiventopeopleyouallowtohaveitbysigningawrittenrelease,ortopeoplewhoneedtoknowyourHIVstatusinordertoprovidemedicalcareandservices,including:medicalcareproviders;personsinvolvedwithfostercareoradoption;parentsandguardianswhoconsenttocareofminors;jail,prison,probationandparoleemployees;emergencyresponseworkersandotherworkersinhospitals,otherregulatedsettingsormedicaloffices,whoareexposedtobloodlbodyfluidsinthecourseoftheiremployment;andorganizationsthatreviewtheservicesyoureceive.StatelawalsoallowsyourHIVinformationtobereleasedunderlimitedcircumstances:byspecialcourtorder;topublichealthofficialsasrequiredbylaw;andtoinsurersasnecessarytopayforcareandtreatment.UnderStatelaw,anyonewhoillegallydisclosesHIVrelatedinformationmaybepunishedbyafineofupto$5,000andajailtermofuptooneyear.However,somere-disclosuresofsuchinformationarenotprotectedunderfederallaw.FormoreinformationaboutHIVconfidentiality,calltheNewYorkStateDepartmentofHealthHIVConfidentialityHotlineat1-800-962-5065.Ifyousignthisform,HIVrelatedinformationcanbegiventothepeoplelistedontheform,andforthereason(s)listedontheform.Youdonothavetosigntheform,andyoucanchangeyourmindatanytimebyindicatingyourchangeinwriting.Uponyourrequest,thefacilityorprovideraskingforthisreleasemustprovideyouwithacopyofthisformassignedbyyouorleftunsigned.ThelawprotectsyoufromHIVrelateddiscriminationinhousing,employment,healthcareandotherservices.FormoreinformationcalltheNewYorkStateDivisionofHumanRightsOfficeofAIDSDiscriminationIssuesat
1(800)523-2437
or(212)480-2493ortheNewYorkCityCommissionofHumanRightsat
(212)306-5070.
Theseagenciesareresponsibleforprotectingyourrights.
"HumanImmunodeficiencyVirusthatcausesAIDS. DOH-2557-HIPAA(Rev.4/03)Page1of2
 
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TheFacility/Providerobtainingthisreleasemustcompletethefollowing:Exceptions,ifany,totherighttorevokeconsentfordisclosure:(forexamplecannotrevokeifdisclosurehasalreadybeenmade.)Descriptionoftheconsequences,ifany,offailingtoconsenttodisclosureupontreatment,payment,enrollment,oreligibilityforbenefits: (Note:Federalprivacyregulationsmayrestrictsomeconsequences.)
Myquestionsaboutthisformhavebeenanswered.IknowthatIdonothavetoallowreleaseofHIVrelatedinformation,andthatIcanchangemymindatanytimeandrevokemyauthorizationbywritingthefacility/providerobtainingthisrelease.
DOH-2557-HIPAA(Rev.4/03)Page2of2

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