NYIA FORM TEMPLATE-page 1
NYIA FORM TEMPLATE-page 1
NYIA FORM TEMPLATE-page 1
Telephone Number Email Address
o Landline o Mobile
A legally authorized representative for the purpose of sharing health information is defined as “a person or
agency authorized by state, tribal, military or other applicable law, court order or individual’s consent to act on
behalf of a person for the release of medical information.” If you are signing this form on behalf of the individual,
you must provide a copy of the authorization/legal document authorizing you to complete this form, unless this
information has already been provided to New York Medicaid Choice.