Allergy & Asthma Center
Anita N. Wasan, MD, FAAP, FACAAI
6824 Elm Street, Suite 120, McLean, VA 22101
Tel: 703-992-7065, Fax: 703-992-7063
Release of Medical Information
I, the undersigned, have read the above and authorize the staff of the disclosing facility named to disclose such information as herein contained. I understand that this consent may be withdrawn by myself at any time except to the extent that the action has been taken in reliance upon it. I acknowledge and hereby consent that the released information may contain HIV testing, HIV results, and/or AIDS information. The facility (Anita N. Wasan MD PLC) is released and discharged of any liability, and the undersigned will hold the facility harmless for complying with this Authorization for Release of Medical Information.