Rockland County, NY · Rockland County
Authorization for Release of Health Information (HIPAA)
This form authorizes the release of alcohol, drug treatment, and mental 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
- Machine-readable
- JSON record · about the forms index
What this form is
The form is used at the conclusion of a pistol permit application to authorize the release of alcohol or drug treatment and mental health information. It identifies the Rockland County Department of Mental Health Records office and the Rockland County Sheriff BCI Unit as the relevant offices. The document text does not state additional filing instructions.
Who needs it
A person completing a Rockland County pistol permit application who must authorize release of alcohol, drug treatment, or mental health information needs this form.
How to submit it
The form lists the Rockland County Department of Mental Health Records office and the Rockland County Sheriff BCI Unit at 55 New Hempstead Road, New City, New York 10956.
About notarization
This document is signed without a notary; the signer just signs and dates it, and the form does not mention a notarized or sworn attachment.
How to submit this form
- 1
Download the Form
Download the Authorization for Release of Health Information (HIPAA) form.
- 2
Complete the Form
Fill in the form’s requested information and provide the authorization for the pistol permit application.
- 3
Submit the Form
Use the offices and address listed on the form: the Rockland County Department of Mental Health Records or the Sheriff BCI Unit.
Frequently asked questions
- Do I need a notary for the Authorization for Release of Health Information?
- No. This document is signed without a notary; it does not mention a notarized or sworn attachment.
- How do I submit the health information release form?
- The form lists the Rockland County Department of Mental Health Records office and the Sheriff BCI Unit at 55 New Hempstead Road, New City, New York 10956.
- What information does this form authorize for release?
- The form concerns alcohol or drug treatment and mental health information in connection with a pistol permit application.