These instructions will help you to complete the Authorization for Release of Health Information under the HIPAA (OCA960). I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:.The New York Health Care Proxy Law allows you to appoint someone you trust — for example, a family member or close friend – to make health care decisions. This authorization is voluntary. I understand that I can refuse to sign this authorization and The Queen's Health Care Centers. I request that health information regarding my care and treatment be accessed as set forth on this form. I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. This service is available Monday through Friday from 8am to 4 pm EST. The health care provider or social worker must complete section G and H (if requesting an assistance animal). Physician's name and address.