NYS Department of Health Institute
AUTHORIZATION FOR RELEASE OF AIDS CONFIDENTIAL & RELATED INFORMATION
Confidential HIV-Related information is any information indicating that a person had an HIV-related test, or has HIV infection, HIV-related illness or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
Under NYS Law, except for certain people, confidential HIV related information can only be given to persons you allow to have it by signing a release. You can ask for a list of people who can be given confidential HIV related information without a release form.
If you sign this form, HIV related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you sign this form, HIV related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you experience discrimination because of release of HIV related information, you may contact the NYS Division of Human Rights at (212) 370-9624 or the NY City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.
Name of person whose HIV related information will be released: _____________________________________________________
Name & address of person signing this form (if other than above):
Name: _____________________________________________________
Address: _________________________________________________________________
Relationship to person whose HIV information will be released: _______________________________________
Name and address of person who will be given HIV related information: _____________________________________________________
Reason for release of HIV related information:
Time during which release is authorized: From: _______________ To: _______________
My questions about this form have been answered. I know that I do not have to allow release of HIV related information and that I can change my mind at any time.
Date: _______________ Signature: _____________________________________________________
*Human Immunodeficiency Virus that causes AIDS.
DOH 2557(2/89)
January 25, 1999