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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Appendix 5:
OMH-445 - Authorization for Patient Interview

Form OMH 445 (4-03)
New York State Office of Mental Health
AUTHORIZATION FOR PATIENT INTERVIEW
Patient Name   (Last, First, M.I.)                "C" No.
Sex:                                                            Date of Birth
Facility Name:                                             Unit/Ward/Residence No.

If this form is to be signed by a patient, the witness must be a physician who has conducted an interview and examination of the patient and determined that the patient is capable of executing the authorization and is doing so willingly as his/her own voluntary act.

I, the undersigned, hereby consent and authorize the Office of Mental Health and (Interviewer)_________________________________________________________________, a representative of (Organization) __________________________________________________, to interview (Name of Patient) __________________________________, and to use and disseminate information shared during the interview.

I understand that in the course of this interview, I may be disclosing individually identifiable health information about myself to the Interviewer. I also understand that the information obtained at such interview will be used to promote public understanding and support of programs for the mentally disabled.

I also understand that:

  1. Only this information may be used and/or disclosed pursuant to this authorization.
  2. This information is confidential and protected from disclosure.
  3. If this information is disclosed to someone who is not required to comply with federal privacy protection regulations, then it may be redisclosed and would no longer be protected.
  4. I have the right to revoke this authorization at any time. My revocation must be in writing on the form provided to me by (insert name of facility/program)___________________________. I am aware that my revocation is not effective to the extent that the persons I have authorized to use and/or disclose my protected health information have acted in reliance upon this authorization.
  5. I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the New York State Office of Mental Health, nor will it affect my eligibility for benefits.
  6. ________________________may receive compensation for its use/disclosure (I understand this does not apply if I am requesting the use/disclosure).
  7. I have a right to inspect and copy my own protected health information to be used and/or disclosed (in accordance with the requirements of the federal privacy protection regulations found under 45 CFR §164.524

I further understand that this authorization will expire:

When acted upon;

90 Days from this Date;

Other __________________________________________________________________

I certify that I have received a copy of the authorization.

Signature of Patient or Personal Representative
Date
Patient's Name (Printed)
Personal Representative's Name (Printed)
Nature of Personal Representative's Relationship to Patient
Signature of Witness
Date
Witness' Name (Printed)

Comments or questions about the information on this page can be directed to the Office of the Counsel.