Authorization for Release and Complaint Forms

Authorization for Release of Health Information and Confidential HIV Related Information

• English (DOH-2557, Rev. 2/11) (PDF)
  • Form 2557: Technical Assistance Bulletin (Rev. 2/11) (PDF)
• Chinese (DOH-2557, Rev. 2/11) (PDF)
• French (DOH-2557, Rev. 2/11) (PDF)
• Haitian Creole (DOH-2557, Rev. 2/11) (PDF)
• Italian (DOH-2557, Rev. 2/11) (PDF)
• Korean (DOH-2557, Rev. 2/11) (PDF)
• Russian (DOH-2557, Rev. 2/11) (PDF,)
• Spanish (DOH-2557ES, Rev. 2/11) (PDF)

Authorization for Release of Health Information (Including Alcohol/Drug Treatment and Mental Health Information) and Confidential HIV/AIDS Related Information

This form, DOH-5032, was created to facilitate sharing of substance use, mental health and HIV/AIDS information. This form is somewhat like the "Authorization for Release of Medical Information and Confidential HIV Related Information" (DOH-2557), but would fulfill a need to share information within facilities in which different teams handle substance use, mental health and HIV/AIDS-related issues. In addition, the DOH-5032 would fulfill a need to share information between facilities and providers that care for the same patient. Like the DOH-2557, the DOH-5032 is intended to encourage multiple providers to discuss a single individual's care among and between themselves to facilitate coordinated and comprehensive treatment. Although the new form (DOH-5032) may be used in place of DOH-2557, it is not intended to replace any forms currently available.

• English (DOH-5032, April 2011) (PDF)
  • Form 5032: Technical Assistance Bulletin (PDF)
• Arabic (PDF)
• Bengali (PDF)
• Chinese (PDF)
• French (PDF)
• Haitian Creole (PDF)
• Italian (PDF)
• Korean (PDF)
• Polish (PDF)
• Russian (PDF)
• Spanish (PDF)
• Urdu (PDF)
• Yiddish (PDF)

Complaint Report for Alleged Violation of Article 27F

• English (DOH-2865, Rev. 7/14) (PDF)
• Chinese (DOH-2865, Rev. 7/14) (PDF)
• French (DOH-2865, Rev. 7/14) (PDF)
• Haitian Creole (DOH-2865, Rev. 7/14) (PDF)
• Italian (DOH-2865, Rev. 7/14) (PDF)
• Korean (DOH-2865, Rev. 7/14) (PDF)
• Russian (DOH-2865, Rev. 7/14) (PDF)
• Spanish (DOH-2865, Rev. 7/14) (PDF)