HIPPA Authorization Forms

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HIPPA (Health Insurance Portability and Accountability Act) Authorization Forms

Authorization for Use or Disclosure of Protected Health Information

Authorization to Disclose Information to Social Security Administration

Authorization to Disclose Information to North Country Legal Services - developed by North Country Legal Services

NYCHCC Individual Authorization Form

Authorization for Disclosure of Protected Health Information (with notary) - developed by the Legal Aid Society of NYC, Health Law Unit

Authorization for Disclosure of Protected Health Information (without notary) - developed by the Legal Aid Society of NYC, Health Law Unit

Authorization for the Release and/or Discussion of Protected Health Information - developed by Greater Boston Legal Services

Authorization for Release of Behavioral Health Information - developed by Strong Memorial Hospital

Authorization for Release of Medical Information - developed by Strong Memorial Hospital

Empire Justice protects and strengthens the legal rights of people in New York State who are poor, disabled or disenfranchised through: systems change advocacy; training and support to other advocates and organizations,
and high quality direct civil legal representation.

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