Chemung County, NY · Chemung County
HIPAA Authorization
Individuals or their personal representatives use this form to authorize the Chemung County Insurance Department to use or disclose protected health information.
At a glance
- Issued by
- City of Chemung County · Chemung County, Chemung County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- ny-chemungcounty.civicplus.com
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
Use this form when you want to authorize the Chemung County Insurance Department and its business associates to disclose protected health information to named people or entities. It asks for the person’s identifying details, the information to disclose, recipients, purpose, and expiration. The person whose records are involved or a personal representative signs and dates it; representatives must provide legal proof of representation, such as power of attorney.
Who needs it
A person authorizing disclosure of their health information, or their personal representative, completes and signs this form.
How to submit it
Submit it to the county department named on the form; check the county website for current contact details.
About notarization
This authorization is signed and dated without a notary; personal representatives must provide legal proof of representation, such as power of attorney.
How to submit this form
- 1
Download the Form
Download the HIPAA Authorization form.
- 2
Complete the Authorization
Provide the identifying details, select the information to disclose, name recipients, state the purpose, and choose when the authorization expires.
- 3
Gather Representation Proof
If signing as a personal representative, provide legal proof of representation, such as power of attorney.
- 4
Sign and Submit
Sign and date the form, then submit it to the county department named on the form.
Frequently asked questions
- Do I need a notary for the HIPAA Authorization?
- No. The form calls for a signature and date, not notarization. A personal representative must provide legal proof of representation, such as power of attorney.
- How do I submit the HIPAA Authorization?
- Submit it to the Chemung County Insurance Department named on the form. Check the county website for current contact details.
- What information does the authorization cover?
- You can select claim, membership, benefit, or payment information, or describe other information. The form also lets you exclude information and name recipients.
- Who can sign this authorization?
- The person whose records will be used or disclosed may sign. A personal representative may also sign and must provide legal proof of representation, such as power of attorney.