I today give permission for the World Trade Center Medical Program (the “WTCHP”) as well as all other medical sources to share information about me regarding my medical records and my patient file with any and all personnel of 911 Health Watch, a New York not-for-profit corporation located at 100 South Swan Street, Albany, New York, 12210.
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
I have the right to revoke this authorization at any time. I understand that in order to revoke my permission for 911 Health Watch and the WTCHP to disclose my protected health information, I must send a written, signed, and dated revocation to 911 Health Watch at 100 South Swan Street, Albany, New York, 12210 and to the World Trade Center Health Program, 327 Columbia Turnpike, Rensselaer, NY 12144. I may take back (“revoke”) my written permission to 911 Health Watch and to the WTCHP, except to the extent that 911 Health Watch or the WTC Health Program has already acted based on my prior written authorization. I further understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will continue regardless of whether I authorize this disclosure.
Information disclosed under this authorization might be redisclosed by the recipient, and this redisclosure may no longer be protected by federal or state law.
This authorization will expire ten (10) years from the date on which I sign the authorization, unless I revoke it sooner.
The purpose for this authorization is at my request.
By checking this box, I am signing this HIPAA Release authorization.
Federal agencies or other governmental entities may have records related to my activities in the wake of the September 11, 2001 terrorist attacks, or related to the injuries I suffered due to those activities. Pursuant to the Privacy Act of 1974, 5 U.S.C § 552a, I request that any federal agency or other governmental entity disclose those records to 911 Health Watch.
By checking this box I hereby certify that I am the undersigned, and understand that a knowing and willful request for or acquisition of a record pertaining to an individual under false pretenses is a criminal offense under the Privacy Act, subject to a $5,000 fine.
By checking this box, I am signing this Privacy Release authorization.
Your name (required)
Your email (required)
Last updated: February 14, 2020