OCA Official Form 960 "Authorization to Release Health Information Pursuant to Hipaa" - New York

What Is OCA Form 960?

OCA Form 960, Authorization to Release Health Information Pursuant to HIPAA, is a legal document signed by a patient that gives consent to the release of health information within the state of New York. This document gives permission to use protected health information for certain purposes - treatment, payment, and operations, and disclose protected health information to third parties specified by the patient. It ensures the protection of the patients' privacy and allows health data to flow freely between authorized parties for healthcare activities.

Alternate Name:

  • OCA Official Form 960.

If you are seeking your own medical records or wish to give another individual or agency permission to do so on your behalf, complete OCA Official Form 960.

This form was released by the New York State Office of Court Administration. It has replaced Form MAP-751D (Authorization for Disclosure of Health Information) in May 2016. You can download an OCA Form 960 fillable version through the link below.

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How to Fill Out OCA Official Form 960?

Include the following information in the OCA Official Form 960 to request the release of health information:

  1. Write down the name and address of the patient, date of birth, and social security number;
  2. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), a patient must understand the following:
    • You disclose information relating to drug and alcohol abuse, mental health treatment, and HIV-related information;
    • The recipient of the information cannot redisclose it without your authorization. You have the right to request a list of individuals who may receive and use your HIV-related information without authorization. Your rights are protected by the New York State Division of Human Rights and the New York City Commission of Human Rights;
    • You may revoke this authorization at any time;
    • You sign the authorization voluntarily and your treatment and enrollment in health plans cannot be conditioned upon this authorization;
    • Your health information may be redisclosed by the recipient if you specifically authorize it;
    • You only authorize the recipient to discuss your health information with the attorney or governmental agency indicated in the OCA Form 960;
  3. Provide the name and address of the health provider or entity who is authorized to release this information;
  4. Name the individual to whom this information must be sent;
  5. State which information can be released - your medical records from a certain period of time, entire medical records, and information regarding your alcohol or drug treatment, mental health information, or HIV-related information;
  6. Authorize the individual health care provider to discuss your health information with your attorney, or a governmental agency. Name the attorney or agency;
  7. Select the reason for the release of information;
  8. Specify the date or event on which the authorization has to expire;
  9. Name the preparer of the form and indicate the authority to sign on behalf of the patient;
  10. Sign and date the form.
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Download OCA Official Form 960 "Authorization to Release Health Information Pursuant to Hipaa" - New York

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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
Patient Address
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 the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If
I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:
8. Name and address of person(s) or category of person to whom th is information will be sent:
9(a). Specific information to be released:
q Medical Record from (insert date) ___________________ to (insert date) ___________________
q Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
q Other: __________________________________
Include: (Indicate by Initialing)
__________________________________
________ Alcohol/Drug Treatment
________ Mental Health Information
Authorization to Discuss Health Information
________ HIV-Related Information
(b) q By initialing here ____________ I authorize ________________________________________________________________
Initials
Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:
______________________________________________________________________________________________________
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
11. Date or event on which this authorization will expire:
q At request of individual
q Other:
12. If not the patient, name of person signing form:
13. Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
copy of the form.
______________________________________________
Date: _____________________________
Signature of patient or representative authorized by law.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
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
Patient Address
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 the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996
(HIPAA), I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH
TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on
the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I
initial the line on the box in Item 9(a), I specifically authorize release of such information to the person(s) indicated in Item 8.
2. If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is
prohibited from redisclosing such information without my authorization unless permitted to do so under federal or state law. I
understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If
I experience discrimination because of the release or disclosure of HIV-related information, I may contact the New York State Division
of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are
responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may
revoke this authorization except to the extent that action has already been taken based on this authorization.
4. I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for
benefits will not be conditioned upon my authorization of this disclosure.
5. Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this
redisclosure may no longer be protected by federal or state law.
6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL
CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9 (b).
7. Name and address of health provider or entity to release this information:
8. Name and address of person(s) or category of person to whom th is information will be sent:
9(a). Specific information to be released:
q Medical Record from (insert date) ___________________ to (insert date) ___________________
q Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films,
referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
q Other: __________________________________
Include: (Indicate by Initialing)
__________________________________
________ Alcohol/Drug Treatment
________ Mental Health Information
Authorization to Discuss Health Information
________ HIV-Related Information
(b) q By initialing here ____________ I authorize ________________________________________________________________
Initials
Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here:
______________________________________________________________________________________________________
(Attorney/Firm Name or Governmental Agency Name)
10. Reason for release of information:
11. Date or event on which this authorization will expire:
q At request of individual
q Other:
12. If not the patient, name of person signing form:
13. Authority to sign on behalf of patient:
All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a
copy of the form.
______________________________________________
Date: _____________________________
Signature of patient or representative authorized by law.
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could
identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
Instructions for the Use
of the HIPAA-compliant Authorization Form to
Release Health Information Needed for Litigation
This form is the product of a collaborative process between the New York State
Office of Court Administration, representatives of the medical provider community in
New York, and the bench and bar, designed to produce a standard official form that
complies with the privacy requirements of the federal Health Insurance Portability and
Accountability Act (“HIPAA”) and its implementing regulations, to be used to authorize
the release of health information needed for litigation in New York State courts. It can,
however, be used more broadly than this and be used before litigation has been
commenced, or whenever counsel would find it useful.
The goal was to produce a standard HIPAA-compliant official form to obviate the
current disputes which often take place as to whether health information requests made in
the course of litigation meet the requirements of the HIPAA Privacy Rule. It should be
noted, though, that the form is optional. This form may be filled out on line and
downloaded to be signed by hand, or downloaded and filled out entirely on paper.
When filing out Item 11, which requests the date or event when the authorization
will expire, the person filling out the form may designate an event such as “at the
conclusion of my court case” or provide a specific date amount of time, such as “3 years
from this date”.
If a patient seeks to authorize the release of his or her entire medical record, but
only from a certain date, the first two boxes in section 9(a) should both be checked, and
the relevant date inserted on the first line containing the first box.
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