Authorization Form For Advocacy Program Page 1


AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION

Patient’s Name:

 

Date of Birth:

 

Previous Name:

 

Social Security #:

 

I request and authorize

 

to

release health care information of the patient named above to:

 

Name:

Dr. Patty Hagler-Verdugo, PysD.

 

Address:

 
 

City:

 

State:

NV

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 ONE (1) YEAR AFTER IT IS SIGNED.

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