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Terms & Conditions of HIPAA Authorizations

By accepting the terms or conditions you or your authorized representative, request that health information regarding your care and treatment be released and exchanged as set forth by these terms and conditions in accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), You understand that:


This authorization includes the disclosure of your health record including information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION.  You understand that you have the right to request a list of people who may receive or use my HIV-related information without authorization.  If you experience discrimination because of the release or disclosure of HIV-related information, you may contact the New York State Division of Human Rights at 1 (212) 480- 2493 or the New York City Commission of Human Rights at 1 (212) 306-7450.  These agencies are responsible for protecting your rights.  You have the right to revoke this authorization at any time by writing to the East End Mental Health at 332 West Montauk Highway Suite 5 Hampton Bays, New York 11946.  You understand that you may revoke this authorization except to the extent that action has already been taken based on this authorization.  You understand that agreeing to this authorization is voluntary.  Your treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon your authorization of this disclosure.  Information disclosed under this authorization might be redisclosed by the recipient and this redisclosure may no longer be protected by federal or state law (with exception to HIV-related information).  THIS AUTHORIZATION DOES NOT AUTHORIZE EAST END MENTAL HEALTH TO DISCUSS YOUR HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE PARTY EXPRESSLY AGREED UPON.

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