Authorization of Health Release Form

The Authorization of Health Release Form enables family, friends, or others to obtain health information relating to individuals in custody in the New York State Department of Corrections and Community Supervision (DOCCS). Current privacy laws protect the confidentiality of medical information and prohibits staff from disclosing an individual's medical information to family members, friends, or others without written authorization.

However, a properly completed and signed Department of Health Form 5032 can provide family, friends or others the ability to obtain medical information about individuals who are incarcerated, including information on alcohol/drug treatment, mental health, and confidential HIV/AIDS. This information will only be released when if the patient or authorized representative specifies the information to be disclosed and executes the document by initialing the it on the appropriate line of the form.

NOTE: Mental Health records are maintained by the Office of Mental Health and cannot be released by DOCCS.

The Form requires the following information:

• Incarcerated Individual's Name
• Date of Birth
• Department Identification Number (DIN)
• Current Address (Line 5)

NYS Department of Corrections and Community Supervision
Harriman State Campus
1220 Washington Avenue
Albany, New York 12226

• Name and address of person(s) receiving information. (Line 6). For multiple releases, please attach a separate sheet with each name and address. Additional individuals may not be added after the release form has been signed and dated by the patient or authorized representative. Additional individuals may only be added by completing a separate Form DOH-5032.
• Specific purpose for release of information (Line 7).
• Dates for authorized release (Line 8). Expiration date must be included. To obtain medical information about a loved one while they are currently incarcerated, it is highly recommended to note “Until I am released from DOCCS custody” as an expiration date.
• Authorized representative’s consent (Lines 9 & 10). Includes the name and signature of authorized representative, as well as the signature of the patient or representative authorized by law and the date the form is signed. This form is incomplete until representatives authorized by law have signed and dated the form, authorizing that they reviewed the form and they understand it. Once the form has been signed and dated, the form must not be changed in any way.

This form is also incomplete until the provider or staff person from the facility has signed and dated it acknowledging witness to the execution and a copy of the signed authorization was provided to the patient and/or the patient’s authorized representative.

Family Members. Leave the patient signature line blank unless you are the legal representative -- a court appointed legal guardian, health care agent appointed by a valid health care proxy -- and are signing on behalf of the that incarcerated family member. If not, mail the completed form to the family member for a signature that must be conducted in the presence of a facility staff member, such as a nurse, doctor, ORC, or correction officer. Each one can sign as a witness to the signature before giving the form to medical staff to be placed in their medical record. The patient will receive a copy of the form.

Incarcerated Patients. Signatures must be witnessed by a facility staff member, such as a nurse, doctor, ORC, or correction officer. DO NOT SIGN THE FORM WITHOUT A WITNESS. You can submit signed forms to the medical staff to be placed in your medical record. You will receive a copy of the form.