Home and Community Based Services Waiver
Guidance Document
Division of Children and Families

400.3

Authorization for Release of Information

For an agency to obtain information from another source outside of Office Mental Health and to share information outside of the Office of Mental Health, a Authorization for Release of Information (Español versión HTML) is required. A One-Time Authorization to Release Information expires when acted upon or 90 days from the date the information is requested, whichever comes first. A Consent for Periodic Release expires within a year or when the individual no longer receives services, whichever comes first.  For the HCBS Waiver program wherein children are under the age of 18, only the responsible parent, relative or guardian must sign. 

Elements

The following elements must be included:

• Identifying information related to patient
• Extent or nature of information to be disclosed
• Purpose or need for information
• Name and address of person/organization/facility/program disclosing the requested information
• Name and address of person/organization/facility/program to which the disclosure is to be made
• Signature and dates signed for authorization of release by a) patient or person acting for patient with relationship to patient and b) witness with title,

Note: The above signatures are required for refusals to authorize releases of information or cancellations of permission.

• Signature of staff person releasing information, title and date released.

A standard Authorization for Release of Information is available through the OMH Central Office Utica Press (Form OMH 11, 5-87).