Consent Form and Authorization of Treatment

Complete this before your appointment and your provider can be better prepared during their time with you.

Consent Form

Authorization for Access to Patient Information Through a Health Information Exchange Organization

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose wheter or not to allow the Organization named above to obtain access to my Medical Records through the health information exchange organization called Health Connections. If I give consent, my Medical Records from different places where I get health care can be accessed using a statewide computer network. Health Connections is a non-for-profit organization that shares information about people's health electronically and meets the privacy and security standards of HIPPA and New York State Law. To learn more visit Health Connections website at http://healtheconnections.org/. The Choice I make on this form will NOT affect my ability to get medical care. The choice I make on this form does NOT allow health insurers to have access to my information for the purpose of deciding wheter to provide me with health insurance coverage or pay my medical bills.


Authorization of Treatment