# New York HIPAA release form: OCA Form 960, item by item

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By [Arthur Teboul](/authors/arthur-teboul), Founder, DokuTrak. Published 2026-11-03, updated 2026-11-03.

> **In brief:** The standard HIPAA release form in New York is OCA Official Form No. 960, the court system’s authorization for release of health information ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). It covers records for litigation and other uses, needs separate initials for HIV, mental health and alcohol or drug treatment records, and cannot release psychotherapy notes ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)).

## What is a New York HIPAA release form?

**OCA Official Form No. 960** is the New York court system’s “Authorization for Release of Health Information Pursuant to HIPAA” ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). Its instructions say it came out of work between the Office of Court Administration, medical providers, judges and lawyers, to end disputes over whether litigation requests met the Privacy Rule ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).

The form is optional, and it can be used before a case is filed or whenever counsel finds it useful ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). Its statements match the federal list explained in the general [HIPAA release form](/documents/hipaa-release-form) guide, so a provider can check it quickly.

One limit is printed on the courts’ forms page: neither court HIPAA form may be used to authorize the release of psychotherapy notes ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)). Those need their own authorization under the federal rule ([45 CFR 164.508, Authorizations](https://www.law.cornell.edu/cfr/text/45/164.508)).

## Who sends it, and when

The patient signs it, or someone with legal authority to sign for the patient, who then states that authority on the form ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). In practice, a personal injury or malpractice firm, an insurer or a government benefits office fills in most fields and sends it to the client to sign. At the provider, **health information management** is the department that receives the form, checks it and releases the records.

## Where to get a New York HIPAA release form

1. Download the fillable PDF from the New York courts’ HIPAA forms page; it can be completed on screen and signed by hand ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).
2. Fill in one copy for each provider or facility that holds records.
3. Have the patient initial each special category they agree to release, and sign and date the form.
4. Give the patient a copy, then send the original to the provider’s records department with a cover letter.

## Wrong files people send instead

- Item 9(a) categories left without initials, so HIV, mental health or drug treatment records are withheld ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).
- Psychotherapy notes requested on the form, which the courts say it cannot authorize ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)).
- Expecting the provider to talk to a lawyer when the box in Item 9(b) was never initialed ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).
- A representative’s signature with Items 12 and 13 blank ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).
- Using Form 960 for HIV-related records outside litigation when the provider asks for the Department of Health’s form DOH-2557 ([New York State Department of Health form DOH-2557](https://www.health.ny.gov/forms/doh-2557.pdf)).

## Form 960 item by item

The first six items are statements the patient reads; the rest are blanks. The table follows the printed order ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).

- For the entire record from a given date onward, the instructions say to check the first two boxes of Item 9(a) and write the start date on the first line ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).
- For Item 11, the instructions give examples such as “at the conclusion of my court case” or a span like “3 years from this date” ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).

| Item | What it says or asks | How to complete it |
| --- | --- | --- |
| Top block | Patient name, date of birth, Social Security number, address | Match the provider’s chart; ask whether the full SSN is needed |
| Items 1 and 2 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Special categories need initials; recipient may not redisclose them unless the law allows | Read only; the initials go in Item 9(a) |
| Items 3 to 5 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Revocation in writing, no conditioning of care, redisclosure warning | Read only |
| Item 6 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | No discussion with anyone except the attorney or agency in Item 9(b) | Read only |
| Item 7 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Provider releasing the information | Full name and records address |
| Item 8 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Person or category receiving it | Firm, insurer or agency with address |
| Item 9(a) ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Date range, entire record, or other; initials for alcohol or drug treatment, mental health and HIV-related information | Initial only the categories the patient agrees to release |
| Item 9(b) ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Permission for a named provider to discuss care with the patient’s attorney or a government agency | Initial and name both, or leave blank |
| Items 10 and 11 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Reason for release; expiration date or event | “At request of individual” or a stated reason; a date or event |
| Items 12 and 13 ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)) | Name and authority of a signer who is not the patient | For example, guardian or administrator of the estate |

## HIV-related, mental health and drug treatment records

In New York, **confidential HIV-related information** is any information showing that a person had an HIV-related test or has HIV infection, HIV-related illness or AIDS ([New York State Department of Health form DOH-2557](https://www.health.ny.gov/forms/doh-2557.pdf)). Public Health Law 2782 bars its disclosure except to listed people, such as someone named in a valid release ([New York Public Health Law 2782](https://www.nysenate.gov/legislation/laws/PBH/2782)). On Form 960, that information leaves the provider only if the patient initials the HIV line ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)).

The Department of Health also publishes form DOH-2557, which lets a patient release non-HIV information, HIV-related information, or both, to several named facilities ([New York State Department of Health form DOH-2557](https://www.health.ny.gov/forms/doh-2557.pdf)). Providers sometimes prefer it when HIV-related records are requested outside a lawsuit.

An insurer asking for HIV-related information outside its claims work needs a dated, written authorization stating the nature of the information and the purposes of the disclosure ([New York Public Health Law 2782](https://www.nysenate.gov/legislation/laws/PBH/2782)).

Initialing the alcohol or drug line may not be enough on its own. A federally assisted substance use disorder program may require a consent that meets 42 CFR 2.31, and its SUD counseling notes need a separate consent ([42 CFR 2.31, Consent requirements for substance use disorder records](https://www.law.cornell.edu/cfr/text/42/2.31)).

## The second court form: interviewing a treating physician

The courts’ page lists a second document, the Authorization to Permit Interview of Treating Physician by Defense Counsel ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)). It does not release records; it concerns a conversation between defense counsel and a named physician ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)).

The same psychotherapy notes limit applies to it ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)). A plaintiff’s firm usually sees this form from the other side, so check the conditions listed before the client signs.

## Copy fees and timing in New York

When a patient or other qualified person asks a New York provider for copies, Public Health Law 18 caps paper copies at 75 cents per page ([New York Public Health Law 18, Access to patient information](https://www.nysenate.gov/legislation/laws/PBH/18)). The same section says a qualified person may not be denied access only because they cannot pay ([New York Public Health Law 18, Access to patient information](https://www.nysenate.gov/legislation/laws/PBH/18)).

No charge applies when the records support an application, claim or appeal for a government benefit or program ([New York Public Health Law 18, Access to patient information](https://www.nysenate.gov/legislation/laws/PBH/18)). Under the federal rule, the provider acts on a patient’s access request within 30 days, with one extension of up to 30 days ([45 CFR 164.524, Right of access](https://www.law.cornell.edu/cfr/text/45/164.524)).

A firm requesting records on a signed authorization may be billed differently from a patient asking for their own copy, so ask the provider for its fee before the records ship.

## The template: Cover letter sending OCA Form 960 to a New York provider

**Not advice.** This page is general information, not tax, legal or HR advice. Rules change: check the cited source and ask your own professional before you rely on it. Last reviewed October 25, 2026.

Send this letter with the signed Form 960, one letter per facility. Delete the attorney discussion paragraph if Item 9(b) is blank, and the HIV paragraph if the HIV line was not initialed.

```text
[Your name or firm name]
[Street address, city, NY ZIP] | [Phone] | [Email]
[Date]

To: Health Information Management / Release of Information
[Hospital or practice name]
[Records address]
Re: Records request for [Patient full name], date of birth [MM/DD/YYYY]

Dear Records Custodian,

Enclosure
Enclosed is OCA Official Form No. 960, signed by [the patient / the patient’s representative, whose authority is stated in Items 12 and 13] on [date of signature].

Records requested
Please release the records described in Item 9(a): [the entire medical record / records from (start date) to (end date)], including [itemized billing / imaging reports / films on disc]. Psychotherapy notes are not requested.

Special categories
The patient has initialed Item 9(a) for: [alcohol or drug treatment / mental health information / HIV-related information]. Please include only the categories initialed. If your program needs its own 42 CFR Part 2 consent for substance use records, please tell us. SUD counseling notes are not requested.

HIV-related information (optional)
If your facility requires form DOH-2557 for HIV-related information, please tell us and we will send it signed.

Discussion with counsel (optional)
Item 9(b) is initialed, authorizing [Provider name] to discuss the patient’s health information with [Attorney or agency name]. Please share a direct number for that conversation.

Format and fees
We prefer [paper copies / an electronic copy]. Please send an invoice before release if the fee exceeds $[amount]. If this request is for a government benefit claim, please note it on your invoice.

Contact
Questions about this request can go to [Name] at [phone] or [email]. Please quote our reference [file or matter number].

Sincerely,

____________________
[Name]
[Title]
Enclosure: OCA Official Form No. 960
```

Download: [Word](https://dokutrak.com/downloads/pseo-v2/f6-document-guides/hipaa-release-form/new-york.docx) · [PDF](https://dokutrak.com/downloads/pseo-v2/f6-document-guides/hipaa-release-form/new-york.pdf)

## Questions people ask

### Is there a standard HIPAA release form in New York?

Yes. OCA Official Form No. 960 is the court system’s standard authorization, built with providers and the bar to settle disputes over litigation requests ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). Using it is optional, and many facilities also keep their own forms.

### Can Form 960 release psychotherapy notes?

No. The New York courts state that their HIPAA forms may not be used to authorize the release of psychotherapy notes ([New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml)). A separate authorization limited to those notes is needed ([45 CFR 164.508, Authorizations](https://www.law.cornell.edu/cfr/text/45/164.508)).

### Does Form 960 have to be notarized?

The printed form ends with the signature of the patient or authorized representative and the date, with no notary block ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). A provider may still have its own identity checks, so ask the records office.

### How do I revoke a New York HIPAA authorization?

Write to the health care provider listed on the form. Revocation works except for actions already taken based on the authorization ([New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf)). Federal rules add a second exception: if you signed to obtain insurance coverage, other law may let the insurer contest a claim ([45 CFR 164.508, Authorizations](https://www.law.cornell.edu/cfr/text/45/164.508)).

## Sources

- [New York OCA Official Form No. 960 and its instructions](https://ww2.nycourts.gov/forms/Hipaa_fillable.pdf): Lists the form’s items, the initials required for alcohol or drug, mental health and HIV-related information, the attorney discussion box, and instructions on scope, expiration and optional use.
- [New York State Unified Court System, HIPAA forms](https://ww2.nycourts.gov/forms/hipaa.shtml): The two court HIPAA forms may not be used to obtain an authorization for release of psychotherapy notes.
- [New York Public Health Law 2782](https://www.nysenate.gov/legislation/laws/PBH/2782): Limits disclosure of confidential HIV-related information to listed persons, including those named in a release, and sets conditions for insurers.
- [New York State Department of Health form DOH-2557](https://www.health.ny.gov/forms/doh-2557.pdf): State form to release health information and confidential HIV-related information to named facilities or persons.
- [New York Public Health Law 18, Access to patient information](https://www.nysenate.gov/legislation/laws/PBH/18): Paper copies may not exceed 75 cents per page, inability to pay cannot be the only reason to deny access, and no charge applies for government benefit claims.
- [45 CFR 164.508, Authorizations](https://www.law.cornell.edu/cfr/text/45/164.508): A use or disclosure of psychotherapy notes requires an authorization that may only be combined with another psychotherapy notes authorization; revocation is limited by reliance and by an insurer’s right to contest where coverage was conditioned on it.
- [42 CFR 2.31, Consent requirements for substance use disorder records](https://www.law.cornell.edu/cfr/text/42/2.31): A Part 2 consent must carry its own listed elements; SUD counseling notes need a separate consent; a consent for use in legal proceedings cannot be combined with any other consent.
- [45 CFR 164.524, Right of access](https://www.law.cornell.edu/cfr/text/45/164.524): A provider must act on an access request within 30 days, with one extension of up to 30 days.

## More on this topic

- [HIPAA release form](/documents/hipaa-release-form)
- [Law firm client intake checklist](/tools/document-checklist/law-firm-client-intake)

## About the author

Arthur Teboul (Founder, DokuTrak) is building DokuTrak after watching professionals lose hours chasing clients for documents over email. [Arthur Teboul](/authors/arthur-teboul).

How this page was made (methodology): it is built from the primary sources listed under Sources, and every rule and figure on it links to the source it comes from. Last updated October 25, 2026. Spotted an error or a rule that changed? [Contact us](/contact).