Do I need a notary for the HIPAA health information release form?

No. The form is signed without a notary; its instructions say to download it and sign by hand, and state no notarized attachment or related step.

What information does the authorization request?

It asks for patient and provider details, the recipient, the health information to release, the reason, an expiration date or event, and the signer’s authority.

Can I use this form before a court case begins?

Yes. The instructions say the form can be used for litigation, before litigation has commenced, or whenever counsel finds it useful.

Rockland County, NY · Rockland County

No notary required

Authorization for Release of Health Information (HIPAA)

This HIPAA authorization lets a patient or authorized representative request release of health information to a person or organization they identify.

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 authorization to request release of health information, including specified medical records, to the person or category of recipients entered on the form. The instructions say it can be used for litigation or more broadly whenever counsel finds it useful, and that the form is optional. It asks for patient details, the provider and recipient, the information to release, the reason, an expiration date or event, and the signer’s authority.

Who needs it

A patient or authorized representative can complete this form to authorize a health care provider to release specified information to identified recipients.

How to submit it

Submit it to the county office named on the form; check the county website for current contact details and submission instructions.

About notarization

This document is signed and dated without a notary; the instructions say to download it and sign by hand, with no notarized attachment or related step stated.

How to submit this form

1
Download the Form
Download the authorization form; the instructions allow it to be filled out online or on paper.
2
Complete the Form
Enter the patient, provider, recipient, requested information, reason, expiration, and signer details.
3
Review and Sign
Review the completed form, then sign it by hand and date it.
4
Submit to the County
Submit the form to the county office named on it; check the county website for current contact details.

Frequently asked questions

Do I need a notary for the HIPAA health information release form?: No. The form is signed without a notary; its instructions say to download it and sign by hand, and state no notarized attachment or related step.
How do I submit the health information release form?: Submit it to the county office named on the form. Check the county website for current contact details and submission instructions.
What information does the authorization request?: It asks for patient and provider details, the recipient, the health information to release, the reason, an expiration date or event, and the signer’s authority.
Can I use this form before a court case begins?: Yes. The instructions say the form can be used for litigation, before litigation has commenced, or whenever counsel finds it useful.

Need something notarized?

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