Lily W. Eng, DDS 101 Lafayette Street, 9th Floor, New York, NY 10013 212-842-5300, 212-842-8042
Lily W. Eng, DDS
101 Lafayette Street, 9th Floor, New York, NY 10013
212-842-5300, 212-842-8042
I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:
All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.
Use your mouse cursor or the tip of your finger to sign below
Your exported signature
Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was provided to the patient and/or the patient’s authorized representative.
This form may be used in place of DOH-2557 and has been approved by the NYS Office of Mental Health and NYS Office of Alcoholism and Substance Abuse Services to permit release of health information. However, this form does not require health care providers to release health information. Alcohol/drug treatment-related information or confidential HIV-related information released through this form must be accompanied by the required statements regarding prohibition of re-disclosure.
*Note: Information from mental health clinical records may be released pursuant to this authorization to the parties identified herein who have a demonstrable need for the information, provided that the disclosure will not reasonably be expected to be detrimental to the patient or another person.