www.essenhealthcare.com Open in urlscan Pro
51.8.36.30  Public Scan

Form analysis
2 forms found in the DOM

<form _ngcontent-ng-c864481459="" novalidate="" id="frmPatient" class="ng-untouched ng-pristine ng-invalid">
  <div _ngcontent-ng-c864481459="" id="wrapper" class="container">
    <div _ngcontent-ng-c864481459="" class="row">
      <div _ngcontent-ng-c864481459="" class="col-sm-12 text-center">
        <p _ngcontent-ng-c864481459="" class="grey-txt"><b _ngcontent-ng-c864481459="">AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA</b><br _ngcontent-ng-c864481459=""> [This form has been approved by the New York State Department
          of Health] </p>
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12">
        <h1 _ngcontent-ng-c864481459="" class="custom-heading-43"> HIPAA Authorization for Release of Health Information </h1>
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-6 my-3 form-group"><label _ngcontent-ng-c864481459="">Name <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><input _ngcontent-ng-c864481459="" type="text"
          placeholder="First" id="firstname" name="firstname" required="" aria-required="true" class="form-control" value=""><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-6 my-3 form-group"><label _ngcontent-ng-c864481459="">&nbsp;</label><input _ngcontent-ng-c864481459="" type="text" name="lastname" placeholder="Last" required="" aria-required="true"
          class="form-control" value=""><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
        <div _ngcontent-ng-c864481459="" class="col-sm-12"><label _ngcontent-ng-c864481459="">Date of Birth <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><br _ngcontent-ng-c864481459=""><p-calendar
            _ngcontent-ng-c864481459="" name="dOB" id="dOB" dateformat="mm/dd/yy" datatype="string" class="p-element p-inputwrapper width-200 form-control ng-tns-c63392258-0" required="" ngh="2"><span
              class="ng-tns-c63392258-0 p-calendar p-calendar-w-btn"><input type="text" role="combobox" aria-autocomplete="none" aria-haspopup="dialog" autocomplete="off" pautofocus=""
                class="p-element ng-tns-c63392258-0 p-inputtext p-component ng-star-inserted" value="" placeholder="" name="dOB" required="true" aria-required="true" aria-expanded="false"><!----><button type="button" aria-haspopup="dialog" pbutton=""
                pripple="" tabindex="0" class="p-element p-ripple p-datepicker-trigger p-button-icon-only ng-tns-c63392258-0 p-button p-component ng-star-inserted" aria-label="Choose Date" aria-expanded="false"><!---->
                <calendaricon class="p-element p-icon-wrapper ng-tns-c63392258-0 ng-star-inserted" ngh="1"><svg width="14" height="14" viewBox="0 0 14 14" fill="none" xmlns="http://www.w3.org/2000/svg" class="p-icon" aria-hidden="true">
                    <path
                      d="M10.7838 1.51351H9.83783V0.567568C9.83783 0.417039 9.77804 0.272676 9.6716 0.166237C9.56516 0.0597971 9.42079 0 9.27027 0C9.11974 0 8.97538 0.0597971 8.86894 0.166237C8.7625 0.272676 8.7027 0.417039 8.7027 0.567568V1.51351H5.29729V0.567568C5.29729 0.417039 5.2375 0.272676 5.13106 0.166237C5.02462 0.0597971 4.88025 0 4.72973 0C4.5792 0 4.43484 0.0597971 4.3284 0.166237C4.22196 0.272676 4.16216 0.417039 4.16216 0.567568V1.51351H3.21621C2.66428 1.51351 2.13494 1.73277 1.74467 2.12305C1.35439 2.51333 1.13513 3.04266 1.13513 3.59459V11.9189C1.13513 12.4709 1.35439 13.0002 1.74467 13.3905C2.13494 13.7807 2.66428 14 3.21621 14H10.7838C11.3357 14 11.865 13.7807 12.2553 13.3905C12.6456 13.0002 12.8649 12.4709 12.8649 11.9189V3.59459C12.8649 3.04266 12.6456 2.51333 12.2553 2.12305C11.865 1.73277 11.3357 1.51351 10.7838 1.51351ZM3.21621 2.64865H4.16216V3.59459C4.16216 3.74512 4.22196 3.88949 4.3284 3.99593C4.43484 4.10237 4.5792 4.16216 4.72973 4.16216C4.88025 4.16216 5.02462 4.10237 5.13106 3.99593C5.2375 3.88949 5.29729 3.74512 5.29729 3.59459V2.64865H8.7027V3.59459C8.7027 3.74512 8.7625 3.88949 8.86894 3.99593C8.97538 4.10237 9.11974 4.16216 9.27027 4.16216C9.42079 4.16216 9.56516 4.10237 9.6716 3.99593C9.77804 3.88949 9.83783 3.74512 9.83783 3.59459V2.64865H10.7838C11.0347 2.64865 11.2753 2.74831 11.4527 2.92571C11.6301 3.10311 11.7297 3.34371 11.7297 3.59459V5.67568H2.27027V3.59459C2.27027 3.34371 2.36993 3.10311 2.54733 2.92571C2.72473 2.74831 2.96533 2.64865 3.21621 2.64865ZM10.7838 12.8649H3.21621C2.96533 12.8649 2.72473 12.7652 2.54733 12.5878C2.36993 12.4104 2.27027 12.1698 2.27027 11.9189V6.81081H11.7297V11.9189C11.7297 12.1698 11.6301 12.4104 11.4527 12.5878C11.2753 12.7652 11.0347 12.8649 10.7838 12.8649Z"
                      fill="currentColor"></path>
                  </svg></calendaricon><!----><!----><!----><!---->
              </button><!----><!----><!----><!----></span></p-calendar><!----></div>
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459="">Email <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><input _ngcontent-ng-c864481459="" type="text" name="email" id="email"
          class="form-control" required="" value=""><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459="">Phone <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><input _ngcontent-ng-c864481459="" type="text" name="phone" id="phone"
          placeholder="(000)-000-0000" required="" aria-required="true" class="form-control" value=""><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459="">Social Security Number <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><input _ngcontent-ng-c864481459="" type="text"
          name="ssNumber" id="ssNumber" ngmodel="" required="" aria-required="true" class="form-control" value=""><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459="">Patient Address <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><input _ngcontent-ng-c864481459="" type="text"
          name="address" id="address" required="" aria-required="true" class="form-control" value=""><label _ngcontent-ng-c864481459="" class="normal">Address Line 1</label><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><input _ngcontent-ng-c864481459="" type="text" name="address2" id="address2" required="" aria-required="true" class="form-control" value=""><label _ngcontent-ng-c864481459=""
          class="normal">Address Line 2</label><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-6 col-md-4 my-3"><input _ngcontent-ng-c864481459="" type="text" name="city" id="city" required="" aria-required="true" class="form-control" value=""><label _ngcontent-ng-c864481459=""
          class="normal">City</label><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-6 col-md-4 my-3"><input _ngcontent-ng-c864481459="" type="text" name="state" id="state" required="" aria-required="true" class="form-control" value=""><label _ngcontent-ng-c864481459=""
          class="normal">State</label><!----></div>
      <div _ngcontent-ng-c864481459="" class="col-sm-6 col-md-4 my-3"><input _ngcontent-ng-c864481459="" type="text" name="zip" id="zip" required="" aria-required="true" class="form-control" value=""><label _ngcontent-ng-c864481459=""
          class="normal">Zip / Postal Code</label><!----></div>
    </div>
    <div _ngcontent-ng-c864481459="" class="row">
      <div _ngcontent-ng-c864481459="" class="col-sm-12 mt-5">
        <p _ngcontent-ng-c864481459="" class="grey-txt"> I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form: </p><span _ngcontent-ng-c864481459=""> 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: </span>
        <ol _ngcontent-ng-c864481459="" class="ol-list">
          <li _ngcontent-ng-c864481459=""> This authorization may include disclosure of information relating to ALCOHOL and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and CONFIDENTIAL HIV* RELATED INFORMATION only if I place my
            initials on the appropriate line in Item 9(a). In the event the health information described below includes any of these types of information, and I initial the line on the box in Item 9(a), I specifically authorize release of such
            information to the person(s) indicated in Item 8. </li>
          <li _ngcontent-ng-c864481459=""> If I am authorizing the release of HIV-related, alcohol or drug treatment, or mental health treatment information, the recipient is prohibited from redisclosing such information without my authorization
            unless permitted to do so under federal or state law. I understand that I have the right to request a list of people who may receive or use my HIV-related information without authorization. If I experience discrimination because of the
            release or disclosure of HIV-related information, I may contact the New York State Division of Human Rights at (212) 480-2493 or the New York City Commission of Human Rights at (212) 306-7450. These agencies are responsible for protecting
            my rights. </li>
          <li _ngcontent-ng-c864481459=""> I have the right to revoke this authorization at any time by writing to the health care provider listed below. I understand that I may revoke this authorization except to the extent that action has already
            been taken based on this authorization. </li>
          <li _ngcontent-ng-c864481459=""> I understand that signing this authorization is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned upon my authorization of this disclosure.
          </li>
          <li _ngcontent-ng-c864481459=""> Information disclosed under this authorization might be redisclosed by the recipient (except as noted above in Item 2), and this redisclosure may no longer be protected by federal or state law. </li>
          <li _ngcontent-ng-c864481459=""><strong _ngcontent-ng-c864481459="">THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY SPECIFIED IN ITEM 9
              (b).</strong><br _ngcontent-ng-c864481459=""><br _ngcontent-ng-c864481459=""></li>
          <li _ngcontent-ng-c864481459=""><strong _ngcontent-ng-c864481459="">Name and address of health provider or entity to release this information:(Required)</strong><br _ngcontent-ng-c864481459="">
            <div _ngcontent-ng-c864481459="" class="mar__left-15 ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Me or to" id="Me or to">&nbsp; Me or to<br _ngcontent-ng-c864481459=""></div>
            <div _ngcontent-ng-c864481459="" class="mar__left-15 ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Name Of Person or Entity" id="Name Of Person or Entity">&nbsp; Name Of Person or
              Entity<br _ngcontent-ng-c864481459=""></div><!---->
          </li>
        </ol>
      </div><!---->
      <div _ngcontent-ng-c864481459="" class="col-sm-12">
        <div _ngcontent-ng-c864481459="" class="row">
          <div _ngcontent-ng-c864481459="" class="form-group form-check col-sm-12 col-md-6"><label _ngcontent-ng-c864481459="">9(a). Information to Release Date(s) <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><br
              _ngcontent-ng-c864481459="">
            <div _ngcontent-ng-c864481459="" class="mar__left30"><input _ngcontent-ng-c864481459="" type="checkbox" name="medicalRecInsertDate" required="" class="form-check-input">&nbsp; <label _ngcontent-ng-c864481459="" for="acceptTerms"
                class="form-check-label"> Medical Record from (insert date) </label></div><!---->
          </div><!----><!---->
        </div>
        <div _ngcontent-ng-c864481459="" class="row">
          <div _ngcontent-ng-c864481459="" class="col-sm-12 my-1">
            <table _ngcontent-ng-c864481459="">
              <tbody>
                <tr _ngcontent-ng-c864481459="" style="vertical-align: top;">
                  <td _ngcontent-ng-c864481459="" style="vertical-align: top;" type="checkbox" name="entireMedicalRecords" id="entireMedicalRecords" class="form-check-input"><input _ngcontent-ng-c864481459="" type="checkbox"
                      name="entireMedicalRecords" id="entireMedicalRecords" class="form-check-input ng-untouched ng-pristine ng-valid"></td>
                  <td _ngcontent-ng-c864481459="" class="ps-1"> Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance
                    records, and records sent to you by other health care providers. </td>
                </tr>
              </tbody>
            </table>
          </div>
        </div>
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
        <h3 _ngcontent-ng-c864481459="" class="heading-Blue-34UL">Disclosure of Sensitive Information</h3>
        <p _ngcontent-ng-c864481459="" class="grey-txt">
          <b _ngcontent-ng-c864481459=""> You have the right to refuse disclosure and prevent any other person from disclosing sensitive information related to the following conditions, treatments, or testing. Include (Indicate by checking below): </b>
        </p>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Mental Health Testing/Treatment (except psychotherapy notes)"
            id="Mental Health Testing/Treatment (except psychotherapy notes)"> &nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label" for="Mental Health Testing/Treatment (except psychotherapy notes)"> Mental Health Testing/Treatment
            (except psychotherapy notes) </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Alcohol/Drug Treatment/Testing" id="Alcohol/Drug Treatment/Testing"> &nbsp; <label
            _ngcontent-ng-c864481459="" class="form-check-label" for="Alcohol/Drug Treatment/Testing"> Alcohol/Drug Treatment/Testing </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="HIV/AIDS Related Information" id="HIV/AIDS Related Information"> &nbsp; <label
            _ngcontent-ng-c864481459="" class="form-check-label" for="HIV/AIDS Related Information"> HIV/AIDS Related Information </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Genetic Testing Information" id="Genetic Testing Information"> &nbsp; <label
            _ngcontent-ng-c864481459="" class="form-check-label" for="Genetic Testing Information"> Genetic Testing Information </label><br _ngcontent-ng-c864481459=""></div><!---->
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
        <p _ngcontent-ng-c864481459="" class="grey-txt"><b _ngcontent-ng-c864481459=""> Please note that the information will not be released if not checked. </b></p><input _ngcontent-ng-c864481459="" type="radio" name="IsAuthorize" id="IsAuthorize"
          value="true" required="" class="form-check-input ng-untouched ng-pristine ng-invalid"><label _ngcontent-ng-c864481459="" for="authorize" class="form-check-label"> &nbsp; I authorize the disclosure of
          <u _ngcontent-ng-c864481459=""><b _ngcontent-ng-c864481459="">ALL</b></u> sensitive information </label><br _ngcontent-ng-c864481459=""><input _ngcontent-ng-c864481459="" type="radio" name="IsAuthorize" value="false" id="IsAuthorizeNot"
          required="" class="form-check-input ng-untouched ng-pristine ng-invalid"><label _ngcontent-ng-c864481459="" for="acceptTerms" class="form-check-label">&nbsp; I <u _ngcontent-ng-c864481459=""><b _ngcontent-ng-c864481459="">DO NOT</b></u>
          authorize the disclosure of ANY sensitive information </label><!---->
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
        <hr _ngcontent-ng-c864481459="" class="grey-hr">
        <p _ngcontent-ng-c864481459="" class="grey-txt"><b _ngcontent-ng-c864481459="">Delivery Methods</b><span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></p>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Receive electronic copy of records of Email" id="Receive electronic copy of records of Email">&nbsp;
          <label _ngcontent-ng-c864481459="" class="form-check-label" for="Receive electronic copy of records of Email"> Receive electronic copy of records of Email </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Mail Paper Records" id="Mail Paper Records">&nbsp; <label _ngcontent-ng-c864481459=""
            class="form-check-label" for="Mail Paper Records"> Mail Paper Records </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Fax" id="Fax">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label" for="Fax"> Fax
          </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Patient Portal*" id="Patient Portal*">&nbsp; <label _ngcontent-ng-c864481459=""
            class="form-check-label" for="Patient Portal*"> Patient Portal* </label><br _ngcontent-ng-c864481459=""></div><!---->
        <p _ngcontent-ng-c864481459="" class="grey-txt my-2"> * Patients with an active electronic medical records account (patient portal) can request electronic delivery via secure web patient portal at no cost. Please confirm by checking the box
          above. </p>
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12">
        <p _ngcontent-ng-c864481459="" class="grey-txt"><b _ngcontent-ng-c864481459=""> 9(b). Authorization to Discuss Health Information</b><span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></p><input _ngcontent-ng-c864481459=""
          type="checkbox" id="IsAuthorizationtoDiscussHealthInformation" name="IsAuthorizationtoDiscussHealthInformation" required="" class="form-check-input ng-untouched ng-pristine ng-invalid"><label _ngcontent-ng-c864481459="" for="authorize"
          class="form-check-label normal">&nbsp; By initialing here I authorize</label><br _ngcontent-ng-c864481459=""><!----><!---->
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
        <p _ngcontent-ng-c864481459="" class="grey-txt"><b _ngcontent-ng-c864481459=""> 10. The purpose(s) for which disclosure is authorized (check where applicable):</b><span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></p>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Patient’s request" id="Patient’s request">&nbsp; <label _ngcontent-ng-c864481459=""
            class="form-check-label" for="Patient’s request"> Patient’s request </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Care at another facility / provider" id="Care at another facility / provider">&nbsp; <label
            _ngcontent-ng-c864481459="" class="form-check-label" for="Care at another facility / provider"> Care at another facility / provider </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Life Insurance" id="Life Insurance">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label"
            for="Life Insurance"> Life Insurance </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Legal" id="Legal">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label" for="Legal">
            Legal </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Disability" id="Disability">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label"
            for="Disability"> Disability </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Work’s Comp" id="Work’s Comp">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label"
            for="Work’s Comp"> Work’s Comp </label><br _ngcontent-ng-c864481459=""></div>
        <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Other" id="Other">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label" for="Other">
            Other </label><br _ngcontent-ng-c864481459=""></div><!----><!---->
        <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459="">11. Date or event on which this authorization will expire <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><input
            _ngcontent-ng-c864481459="" type="text" name="authExpire" required="" aria-required="true" class="form-control ng-untouched ng-pristine ng-invalid" value=""><!----></div>
        <div _ngcontent-ng-c864481459="" class="col-sm-6 my-3"><label _ngcontent-ng-c864481459="">12. If not the patient, name of person signing form</label><input _ngcontent-ng-c864481459="" type="text" name="pNameSigForm" placeholder=""
            id="pNameSigForm" value="" aria-required="true" class="form-control ng-untouched ng-pristine ng-valid"></div>
        <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459=""> 13. Authority to sign on behalf of patient (i.e., parent, power of attorney, etc.)</label><br _ngcontent-ng-c864481459="">
          <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Power of Attorney" id="Power of Attorney">&nbsp; <label _ngcontent-ng-c864481459=""
              class="form-check-label" for="Power of Attorney"> Power of Attorney </label><br _ngcontent-ng-c864481459=""></div>
          <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Parents or Patient's Guardians" id="Parents or Patient's Guardians">&nbsp; <label
              _ngcontent-ng-c864481459="" class="form-check-label" for="Parents or Patient's Guardians"> Parents or Patient's Guardians </label><br _ngcontent-ng-c864481459=""></div>
          <div _ngcontent-ng-c864481459="" class="ng-star-inserted"><input _ngcontent-ng-c864481459="" type="checkbox" class="form-check-input" name="Other" id="Other">&nbsp; <label _ngcontent-ng-c864481459="" class="form-check-label" for="Other">
              Other </label><br _ngcontent-ng-c864481459=""></div><!---->
        </div><!----><!---->
        <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><label _ngcontent-ng-c864481459=""> 14. Is patient deceased? <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><br _ngcontent-ng-c864481459=""><input
            _ngcontent-ng-c864481459="" type="radio" name="IsPatientDeceased" id="IsPatientDeceased" value="true" required="" class="form-check-input ng-untouched ng-pristine ng-invalid"><label _ngcontent-ng-c864481459="" for="authorize"
            class="form-check-label">&nbsp; Yes </label><br _ngcontent-ng-c864481459=""><input _ngcontent-ng-c864481459="" type="radio" name="IsPatientDeceased" value="false" id="IsPatientDeceasedNo" required=""
            class="form-check-input ng-untouched ng-pristine ng-invalid"><label _ngcontent-ng-c864481459="" for="authorize" class="form-check-label">&nbsp; No</label><br _ngcontent-ng-c864481459=""><!----><!----></div>
        <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
          <hr _ngcontent-ng-c864481459="" class="grey-hr">
          <p _ngcontent-ng-c864481459="" class="grey-txt">All items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.</p>
          <div _ngcontent-ng-c864481459="" class="row">
            <div _ngcontent-ng-c864481459="" class="col-lg-8 col-sm-12"><label _ngcontent-ng-c864481459="">Signature of patient or representative authorized by law.<span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label>
              <div _ngcontent-ng-c864481459="" id="signature-pad"><canvas _ngcontent-ng-c864481459="" width="500px" id="sign" style="border: rgb(221, 221, 221) 2px dashed;"></canvas><input _ngcontent-ng-c864481459="" type="button" class="clear-btn">
              </div>
            </div>
            <div _ngcontent-ng-c864481459="" class="col-lg-3 col-sm-12"><label _ngcontent-ng-c864481459="">Date <span _ngcontent-ng-c864481459="" class="mandatory">(Required)</span></label><p-calendar _ngcontent-ng-c864481459="" name="submitDate"
                placeholder="MM/DD/YYYY" id="submitDate" dateformat="mm/dd/yy" datatype="string" class="p-element p-inputwrapper form-control ng-tns-c63392258-1 ng-star-inserted ng-untouched ng-pristine ng-invalid" required="" ngh="2"><span
                  class="ng-tns-c63392258-1 p-calendar p-calendar-w-btn"><input type="text" role="combobox" aria-autocomplete="none" aria-haspopup="dialog" autocomplete="off" pautofocus=""
                    class="p-element ng-tns-c63392258-1 p-inputtext p-component ng-star-inserted" value="" placeholder="MM/DD/YYYY" name="submitDate" required="true" aria-required="true" aria-expanded="false"><!----><button type="button"
                    aria-haspopup="dialog" pbutton="" pripple="" tabindex="0" class="p-element p-ripple p-datepicker-trigger p-button-icon-only ng-tns-c63392258-1 p-button p-component ng-star-inserted" aria-label="Choose Date"
                    aria-expanded="false"><!---->
                    <calendaricon class="p-element p-icon-wrapper ng-tns-c63392258-1 ng-star-inserted" ngh="1"><svg width="14" height="14" viewBox="0 0 14 14" fill="none" xmlns="http://www.w3.org/2000/svg" class="p-icon" aria-hidden="true">
                        <path
                          d="M10.7838 1.51351H9.83783V0.567568C9.83783 0.417039 9.77804 0.272676 9.6716 0.166237C9.56516 0.0597971 9.42079 0 9.27027 0C9.11974 0 8.97538 0.0597971 8.86894 0.166237C8.7625 0.272676 8.7027 0.417039 8.7027 0.567568V1.51351H5.29729V0.567568C5.29729 0.417039 5.2375 0.272676 5.13106 0.166237C5.02462 0.0597971 4.88025 0 4.72973 0C4.5792 0 4.43484 0.0597971 4.3284 0.166237C4.22196 0.272676 4.16216 0.417039 4.16216 0.567568V1.51351H3.21621C2.66428 1.51351 2.13494 1.73277 1.74467 2.12305C1.35439 2.51333 1.13513 3.04266 1.13513 3.59459V11.9189C1.13513 12.4709 1.35439 13.0002 1.74467 13.3905C2.13494 13.7807 2.66428 14 3.21621 14H10.7838C11.3357 14 11.865 13.7807 12.2553 13.3905C12.6456 13.0002 12.8649 12.4709 12.8649 11.9189V3.59459C12.8649 3.04266 12.6456 2.51333 12.2553 2.12305C11.865 1.73277 11.3357 1.51351 10.7838 1.51351ZM3.21621 2.64865H4.16216V3.59459C4.16216 3.74512 4.22196 3.88949 4.3284 3.99593C4.43484 4.10237 4.5792 4.16216 4.72973 4.16216C4.88025 4.16216 5.02462 4.10237 5.13106 3.99593C5.2375 3.88949 5.29729 3.74512 5.29729 3.59459V2.64865H8.7027V3.59459C8.7027 3.74512 8.7625 3.88949 8.86894 3.99593C8.97538 4.10237 9.11974 4.16216 9.27027 4.16216C9.42079 4.16216 9.56516 4.10237 9.6716 3.99593C9.77804 3.88949 9.83783 3.74512 9.83783 3.59459V2.64865H10.7838C11.0347 2.64865 11.2753 2.74831 11.4527 2.92571C11.6301 3.10311 11.7297 3.34371 11.7297 3.59459V5.67568H2.27027V3.59459C2.27027 3.34371 2.36993 3.10311 2.54733 2.92571C2.72473 2.74831 2.96533 2.64865 3.21621 2.64865ZM10.7838 12.8649H3.21621C2.96533 12.8649 2.72473 12.7652 2.54733 12.5878C2.36993 12.4104 2.27027 12.1698 2.27027 11.9189V6.81081H11.7297V11.9189C11.7297 12.1698 11.6301 12.4104 11.4527 12.5878C11.2753 12.7652 11.0347 12.8649 10.7838 12.8649Z"
                          fill="currentColor"></path>
                      </svg></calendaricon><!----><!----><!----><!---->
                  </button><!----><!----><!----><!----></span></p-calendar><!----></div>
          </div>
        </div>
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3">
        <hr _ngcontent-ng-c864481459="" class="grey-hr">
        <p _ngcontent-ng-c864481459="" class="grey-txt"><b _ngcontent-ng-c864481459="">
* Human Immunodeficiency Virus that causes AIDS. The New York State Public Health Law protects information which reasonably could identify someone as having HIV symptoms or infection and information regarding a person’s contacts.
</b></p><label _ngcontent-ng-c864481459=""><input _ngcontent-ng-c864481459="" type="checkbox" value="" id="IsConsent" name="IsConsent" required="" class="form-check-input ng-untouched ng-pristine ng-invalid"> I hereby certify that, to the best of my
          knowledge, the provided information is true and accurate. </label><!---->
      </div>
      <div _ngcontent-ng-c864481459="" class="col-sm-12 my-3"><button _ngcontent-ng-c864481459="" type="submit" class="btn">Next &amp; Review</button></div>
    </div>
  </div>
</form>

POST //translate.googleapis.com/translate_voting?client=te

<form id="goog-gt-votingForm" action="//translate.googleapis.com/translate_voting?client=te" method="post" target="votingFrame" class="VIpgJd-yAWNEb-hvhgNd-aXYTce"><input type="text" name="sl" id="goog-gt-votingInputSrcLang"><input type="text"
    name="tl" id="goog-gt-votingInputTrgLang"><input type="text" name="query" id="goog-gt-votingInputSrcText"><input type="text" name="gtrans" id="goog-gt-votingInputTrgText"><input type="text" name="vote" id="goog-gt-votingInputVote"></form>

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CLICK FOR CARE




AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PURSUANT TO HIPAA
[This form has been approved by the New York State Department of Health]


HIPAA AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Name (Required)
 
Date of Birth (Required)

Email (Required)
Phone (Required)
Social Security Number (Required)
Patient Address (Required)Address Line 1
Address Line 2
City
State
Zip / Postal Code

I, or my authorized representative, request that health information regarding my
care and treatment be released as set forth on this form:

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:
 1. This authorization may include disclosure of information relating to ALCOHOL
    and DRUG ABUSE, MENTAL HEALTH TREATMENT, except psychotherapy notes, and
    CONFIDENTIAL HIV* RELATED INFORMATION only if I place my initials on the
    appropriate line in Item 9(a). In the event the health information described
    below includes any of these types of information, and I initial the line on
    the box in Item 9(a), I specifically authorize release of such information
    to the person(s) indicated in Item 8.
 2. If I am authorizing the release of HIV-related, alcohol or drug treatment,
    or mental health treatment information, the recipient is prohibited from
    redisclosing such information without my authorization unless permitted to
    do so under federal or state law. I understand that I have the right to
    request a list of people who may receive or use my HIV-related information
    without authorization. If I experience discrimination because of the release
    or disclosure of HIV-related information, I may contact the New York State
    Division of Human Rights at (212) 480-2493 or the New York City Commission
    of Human Rights at (212) 306-7450. These agencies are responsible for
    protecting my rights.
 3. I have the right to revoke this authorization at any time by writing to the
    health care provider listed below. I understand that I may revoke this
    authorization except to the extent that action has already been taken based
    on this authorization.
 4. I understand that signing this authorization is voluntary. My treatment,
    payment, enrollment in a health plan, or eligibility for benefits will not
    be conditioned upon my authorization of this disclosure.
 5. Information disclosed under this authorization might be redisclosed by the
    recipient (except as noted above in Item 2), and this redisclosure may no
    longer be protected by federal or state law.
 6. THIS AUTHORIZATION DOES NOT AUTHORIZE YOU TO DISCUSS MY HEALTH INFORMATION
    OR MEDICAL CARE WITH ANYONE OTHER THAN THE ATTORNEY OR GOVERNMENTAL AGENCY
    SPECIFIED IN ITEM 9 (b).
    
    
 7. Name and address of health provider or entity to release this
    information:(Required)
    
      Me or to
    
      Name Of Person or Entity
    

9(a). Information to Release Date(s) (Required)

  Medical Record from (insert date)

Entire Medical Record, including patient histories, office notes (except
psychotherapy notes), test results, radiology studies, films, referrals,
consults, billing records, insurance records, and records sent to you by other
health care providers.


DISCLOSURE OF SENSITIVE INFORMATION

You have the right to refuse disclosure and prevent any other person from
disclosing sensitive information related to the following conditions,
treatments, or testing. Include (Indicate by checking below):

  Mental Health Testing/Treatment (except psychotherapy notes)

  Alcohol/Drug Treatment/Testing

  HIV/AIDS Related Information

  Genetic Testing Information


Please note that the information will not be released if not checked.

  I authorize the disclosure of ALL sensitive information
  I DO NOT authorize the disclosure of ANY sensitive information

--------------------------------------------------------------------------------

Delivery Methods(Required)

  Receive electronic copy of records of Email

  Mail Paper Records

  Fax

  Patient Portal*


* Patients with an active electronic medical records account (patient portal)
can request electronic delivery via secure web patient portal at no cost. Please
confirm by checking the box above.

9(b). Authorization to Discuss Health Information(Required)

  By initialing here I authorize


10. The purpose(s) for which disclosure is authorized (check where
applicable):(Required)

  Patient’s request

  Care at another facility / provider

  Life Insurance

  Legal

  Disability

  Work’s Comp

  Other

11. Date or event on which this authorization will expire (Required)
12. If not the patient, name of person signing form
13. Authority to sign on behalf of patient (i.e., parent, power of attorney,
etc.)

  Power of Attorney

  Parents or Patient's Guardians

  Other

14. Is patient deceased? (Required)
  Yes
  No


--------------------------------------------------------------------------------

All items on this form have been completed and my questions about this form have
been answered. In addition, I have been provided a copy of the form.

Signature of patient or representative authorized by law.(Required)

Date (Required)

--------------------------------------------------------------------------------

* Human Immunodeficiency Virus that causes AIDS. The New York State Public
Health Law protects information which reasonably could identify someone as
having HIV symptoms or infection and information regarding a person’s contacts.

I hereby certify that, to the best of my knowledge, the provided information is
true and accurate.
Next & Review

ABOUT US

We truly believe in putting our patients first. We are part of the community we
serve and we understand the challenges and needs of our patients better than any
other practice

LET’S CONNECT


GET IN TOUCH


2614 Halperin Ave
Bronx, NY 10461
718-365-7877
info@essenhealthcare.com Click For Care

QUICK LINKS

 * Virtual Visit Instructions
 * Care Coordination, Community & Social Services
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 * Request Patient Medical Records
 * Pay My Bill

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