POB 5005
Ashland, Virginia 23005
Phone:804-752-3041 Fax: 804-752-3776
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient’s Name: Date of Birth:
Previous Name: 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.
Yes No 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.
Yes No I authorize the release of any records regarding drug, alcohol, or mental health treatment to
the person(s) listed above.
Patient Signature: Date
Signed:
THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.
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