Rockland County, NY · Rockland County
Authorization for Release of Health Information
This authorization lets a pistol permit applicant release alcohol, drug treatment, and mental health information for the 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
This form authorizes the release of alcohol and drug treatment and mental health information in connection with a Rockland County pistol permit application. The text identifies the pistol permit application as the related process and names the Rockland County Sheriff BCI Unit and Montefiore Nyack Hospital. It does not specify additional instructions or requirements for completing the authorization.
Who needs it
A person completing a Rockland County pistol permit application who is asked to authorize release of alcohol, drug treatment, or mental health information needs this form.
How to submit it
The form names the Rockland County Sheriff BCI Unit at 55 New Hempstead Road, New City, New York 10956. It does not provide further submission instructions.
About notarization
This document is signed without a notary; the text identifies no notarized or sworn attachment, so the signer just signs and dates it.
How to submit this form
- 1
Download the Form
Download the health information release authorization for the Rockland County pistol permit application.
- 2
Complete the Authorization
Fill in the authorization to release alcohol, drug treatment, and mental health information.
- 3
Sign and Date
Sign and date the document; the form does not identify a notary requirement.
- 4
Submit to the Sheriff BCI Unit
The form names the Rockland County Sheriff BCI Unit at 55 New Hempstead Road, New City, New York 10956.
Frequently asked questions
- What does this authorization release?
- The form concerns the release of alcohol and drug treatment and mental health information in connection with a Rockland County pistol permit application.
- Who uses this health information release form?
- It is for a person completing a Rockland County pistol permit application who is asked to authorize release of the health information listed on the form.
- Do I need a notary for this health information release?
- No. This document is signed without a notary; the text identifies no notarized or sworn attachment, so the signer just signs and dates it.
- How do I submit this health information release?
- The form names the Rockland County Sheriff BCI Unit, 55 New Hempstead Road, New City, New York 10956. It does not provide further submission instructions.