Fillable New York Authorization for Release of Health Information Pursuant ...
OCA Official Form No.: 960
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA [This form has been approved by the New York State Department of Health]
Patient Name Date of Birth Social Security Number
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: In accordance with New York State Law and...
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