Do I need a notary for the health information release authorization?

No. The patient or authorized representative signs and dates this form; it does not require notarization.

How do I submit the health information release authorization?

The form lists Rockland County Department of Mental Health, Attention: Records, and the Sheriff BCI Unit at 55 New Hempstead Road, New City.

What information does the authorization ask for?

It requests patient and provider details, the recipient, the health information to release, a reason and expiration date, and information about the signer’s authority.

Rockland County, NY · Rockland County

No notary required

Authorization for Release of Health Information

This authorization lets a patient or authorized representative request release of health information for a Rockland County pistol permit application.

At a glance

Issued by: City of Rockland County · Rockland County, Rockland County, New York
Notarization: Not required: file this form without a notary.
Official source: rocklandcountyny.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

Use this form to authorize a health care provider or entity to release specified health information to the person or agency named on the form. The document identifies Rockland County mental health records and the Sheriff’s BCI Unit in connection with a pistol permit application. It asks for patient details, the provider and recipient, the information to release, the reason, an expiration date, and the signer’s authority.

Who needs it

A patient or authorized representative completing a pistol permit application who needs to authorize release of health information may use this form.

How to submit it

The form lists Rockland County Department of Mental Health, Attention: Records, and the Rockland County Sheriff BCI Unit, 55 New Hempstead Road, New City, New York 10956.

About notarization

This document is signed without a notary; the patient or authorized representative signs and dates it.

How to submit this form

1
Download the Form
Download the health information release authorization.
2
Complete the Form
Fill in the patient, provider, recipient, release details, reason, expiration, and signer information.
3
Review and Sign
Review the authorization, then sign and date it.
4
Submit the Form
Use the department and address listed on the form for the Rockland County records and Sheriff BCI Unit.

Frequently asked questions

Do I need a notary for the health information release authorization?: No. The patient or authorized representative signs and dates this form; it does not require notarization.
How do I submit the health information release authorization?: The form lists Rockland County Department of Mental Health, Attention: Records, and the Sheriff BCI Unit at 55 New Hempstead Road, New City.
What information does the authorization ask for?: It requests patient and provider details, the recipient, the health information to release, a reason and expiration date, and information about the signer’s authority.

Need something notarized?

This Authorization for Release of Health Information doesn’t need a notary, but if you have another Rockland County form that does, a commissioned online notary can help.