Release of Information Form

Authorization for Use/Disclosure of Information:

I voluntarily consent to authorize my (Name of school/ therapist/ medical provider) to use or disclose my information during the term of this Authorization to the recipient(s) that I have identified below.

Recipient: I authorize my health care information to be released to the following recipient(s):

Name: Ali Khan, MD or AMK Psychiatry PLLC

Address: 28 E. Old Country Road, Hicksville, NY, 11801. Phone: 516-495-9428, 516-407-7084

Purpose: I authorize the release of my health information for the following specific purpose:

Information to be disclosed: I authorize the release of the following health information: (check the applicable box below)
All of my health information that the provider has in his or her possession, including information relating to any medical history, mental or physical condition and any treatment received by me.
Only the following records or types of health information:

Term: I understand that this Authorization will remain in effect:

From the date of this Authorization until the day
MM slash DD slash YYYY

Until the Provider fulfills this request.

Until the following event occurs:

Redisclosure: I understand that my health care provider cannot guarantee that the recipient will not redisclose my health information to a third party. The third party may not be required to abide by this Authorization or applicable federal and state law governing the use and disclosure of my health information.

NOTE: This Authorization does not extend to HIV test results, outpatient psychotherapy notes, drug or alcohol treatment records that are protected by federal law, or mental health records that are protected by the Lanterman-Petris-Short Act.

Refusal to sign/right to revoke: |I understand that signing this form is voluntary and that if I don’t sign, it will not affect the commencement, continuation or quality of my treatment at the office of Ali Khan, MD. If I change my mind, I understand that I can revoke this authorization by providing a written notice of revocation to the office of Ali Khan, MD. The revocation will be effective immediately upon my health care provider’s receipt of my written notice, except that the revocation will not have any effect on any action taken by my health care provider in reliance on this Authorization before it received my written notice of revocation.

Questions: I may contact the office of Ali Khan, MD, for answers to my questions about the privacy of my health information at 28 E. Old Country Road, Hicksville, NY, 11801 or phone 516-495-9428, 516-407-7084

Signature

Date
MM slash DD slash YYYY

Signature of Witness

If Individual is unable to sign this Authorization, please complete the information below:

Name of Guardian/ Representative
First Last

Legal Relationship

Date
MM slash DD slash YYYY

Witness

Form 2 Generic Medical Record Release Form

Release of Information Form

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