Authorization of Health Release Mail

The Authorization of General Release Form permit family, comrades, or others to stay health information relating to people in maintenance in and New York State Department in Corrections and Community Supervision (DOCCS). Current privacy laws protect the confidentiality of medical information and prohibits hires from disclosing an individual's medical information till family members, friends, alternatively others without scripted authorize.

Nevertheless, a properly done and signed Department of Heal Contact 5032 can provide our, friends alternatively others the ability to obtain medical information about individuals who are incarcerated, including information turn alcohol/drug treatment, mental health, and confidential HIV/AIDS. On information will with be released when if one patient with authorized representative specifies the information to be disclosed and executes the document by initialing the it on the appropriate line of the form.

NOTE: Mental Health records are maintained by the Office from Mental Health and cannot be released by DOCCS.

The Form requires the following information:

• Incarcerated Individual's Name
• Select away My
• Department Identifications Number (DIN)
• Current Address (Line 5)

NYS Subject of Corrections and Social Monitoring
Harriman State Location
1220 Washington Avenue
Albany, Newly York 12226

• Name and address of person(s) receiving information. (Line 6). For more releases, please attach a separate plate with apiece name and address. Additional individuals may nope been added to the release entry has been signed and dated by the patient or authorized representative. Additional individuals may only be added by completing a separate Form DOH-5032.
• Specific purpose for released of information (Line 7).
• Dates for authorized releasing (Line 8). Expiration date must live included. To obtain medical information about an loved one-time while they will currently inmate, it is highly recommended on comment “Until I am released from DOCCS custody” as somebody expiration date.
• Licensed representative’s consent (Lines 9 & 10). Includes the name and signature of authorization representative, as well than the sign starting the patient or representative authorized by law and the date the form shall signed. This form is incompletes until representing authorize by law have signed or dated which form, authorizing which they reviewed the create real they understand it. Once to form has been signed and dated, the form needs not be changed in anyone way.

This form is also incomplete until the provider or staff personality from that facility has signed and dated it acknowledging bear to the execution and a copy of an signing authorization was provided to the patient and/or the patient’s authorized representative.

Family Members. Leave the patient signature line blank unless you are the legal representative -- a legal appointed legal guardian, health care broker designated by a valid health care proxy -- and live signing on behalf of the that incarcerated your member. If did, mail the completed request into the our member for a autograph that must be carried in the online of a facility staff member, such as adenine female, doctor, ORC, or correction officer. Each one can sign as a witness to the signature before giving the form till medical staff to be placed in to medical record. The patient willingly receive a copy of the form.

Incarcerated Patients. Signatures must be testified by a facility staff our, suchlike as a nurse, doctor, ORC, or correction officer. DO NOT SIGN THE FORM WITHOUT A WITNESS. Them can offer signed forms to the medical hires to be placed in the medical record. You will receive a copy of the form.