When used in this Part:
Authorization for Release of Confidential HIV [FN*] Related Information
Confidential HIV-Related Information is any information indicating that a person had an HIV-related test, or has HIV infection, HIV-related illness, or AIDS, or any information which could indicate that a person has been potentially exposed to HIV.
Under New York State Law, except for certain people, confidential HIV-related information can only be given to persons you allow to have it by signing a release. You can ask for a list of people who can be given confidential HIV-related information without a release form.
If you sign this form, HIV-related information can be given to the people listed on the form, and for the reason(s) listed on the form. You do not have to sign the form, and you can change your mind at any time.
If you experience discrimination because of release of HIV related information, you may contact the New York State Division of Human Rights at (212) 870-8624 or the New York City Commission of Human Rights at (212) 566-5493. These agencies are responsible for protecting your rights.
Name of person whose HIV-related information will be released:
____________
Name and address of person signing this form (of other than above):
____________
Relationship to person whose HIV information will be released:
____________
Reason for release of HIV-related information:
____________
Time during which release is authorized:
From: To:
____________
My questions about this form have been answered. I know that I do not have to allow release of HIV- related information, and that I can change my mind at any time.
________
Date
________
Signature
____________
Division of Parole
Form 4136
[FN1] The following do not constitute significant risk: exposure to urine, feces, sputum, nasal secretions, saliva, sweat, tears or vomitus that does not contain visible blood; human bites where there is no direct blood to blood or blood to mucous membrane contact; exposure of intact skin to blood or any other body substance.
[FN*] Human Immunodeficiency Virus that causes AIDS
N.Y. Comp. Codes R. & Regs. Tit. 9 § 8011.2