Authorization For Release of Confidential HIV and Related Information

By completing and returning the form below (provided by the New York State Department of Health), you can authorize us to disclose your protected health information regarding HIV to another individual or organization.

Important Instructions:

  1. Please write the following information at the top of the form:
    • Your Health Insurance Member ID Number
    • Your Date of Birth

  2. Mail or fax your completed form, with the information above, to:
    Univera Healthcare
    P.O. Box 211256
    Eagan, MN 55121
    FAX: (315) 671-7079

  3. Keep a copy of your completed form for your records.

Privacy regulations require that this form be completed in order for us to disclose information to anyone other than you, including your parents if you are 13 years of age or older, and your spouse if you are married. There are some exceptions to the regulations. For example, your personal physician may receive this information from us without your written authorization.

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