Skip to Main Content

Office of Mental Health

Home and Community Based Services Waiver
Guidance Document
Division of Children and Families


Authorization for Release of Information

To view or print PDF files, Adobe Acrobat Reader must be installed on your computer. Download Adobe Acrobat Reader.


For an agency to obtain information from another source outside of Office Mental Health and to share information outside of the Office of Mental Health, a Authorization for Release of Information (Español versión PDF) is required. A One-Time Authorization to Release Information expires when acted upon or 90 days from the date the information is requested, whichever comes first. A Consent for Periodic Release expires within a year or when the individual no longer receives services, whichever comes first.  For the HCBS Waiver program wherein children are under the age of 18, only the responsible parent, relative or guardian must sign. 


The following elements must be included:

Note: The above signatures are required for refusals to authorize releases of information or cancellations of permission.

A standard Authorization for Release of Information is available through the OMH Central Office Utica Press (Form OMH 11).