Patient Resources

Medical Records & HIPAA Release

Front desk staff assisting a patient at Be Well Primary Health Care Center

Medical Records & HIPAA Release

To release your health information — to yourself, to another doctor, or to a law firm or agency — New York State requires a signed authorization on OCA Official Form No. 960, approved by the New York State Department of Health. Our download below includes the instructions and the form itself. Read each line carefully and make sure every box is filled in correctly; an incomplete form has to be returned to you.

Filling out the form

  • Top of the form — the patient’s name, date of birth, Social Security number, and address.
  • Lines 1–6 — read and understand; nothing to fill in.
  • Line 7 — the provider releasing the records. If you are requesting records from us, write “Be Well Primary Health Care Center — 3007 Farragut Rd, Brooklyn, NY 11210”.
  • Line 8 — who receives the records. Write “self” if they are coming to you; otherwise enter the agency or law firm’s name and address.
  • Line 9(a) — what to release: a specific date range, the entire medical record, or check “Other” and describe exactly what you want.
  • Line 9(b) — optional. Check the box and initial if you want us to discuss your health information with your attorney or a government agency, then name your provider and the person or firm.
  • Line 10 — the reason. As the patient, you simply check “At request of individual.”
  • Line 11 — when the authorization ends: a date, or an event such as “at the end of litigation.”
  • Lines 12 and 13 — only if someone other than the patient signs (a guardian, parent, or power of attorney): their printed name and their authority to sign.
  • Bottom — sign and date.

Important: protected categories

If you want us to release alcohol or drug treatment, mental health, or HIV-related information that may be in your record, you must write your initials next to each of those categories in Item 9(a). Leaving those lines blank means we will not release that information. You can revoke this authorization at any time in writing, and signing it is entirely voluntary — your treatment, payment, and coverage do not depend on it.

Download the HIPAA release instructions and form (PDF)

Bring or mail the completed form to 3007 Farragut Road, Brooklyn, NY 11210, or call (718) 253-9355 if you have questions about a records request.