Release Healthcare Information

Patient’s Name:

Previous Name:

Date of Birth:

Social Security #:

I request and authorize to release healthcare information of the patient named above to

Name

Address

City

State

Zip Code:

This request and authorization applies to:

Healthcare information relating to the following treatment, condition, or dates:

All healthcare information

Other

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

YesNo

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the
person(s) listed above.

YesNo

Patient Signature

Date Signed:

(THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.)