Authorization to Release Medical Records

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Patient Name:
Please type your first and last name above.
Date of Birth:

MonthDayYear
Please type your birthdate above.
Previous Name:
Please type a previous name that you may be known as to the transferring entity (clinic, hospital, etc...)
SSN:
Please type the social security number of the patient requesting medical records if desired (optional).
I request and authorize:
Name of the facility where you would want us to get your records from
This request and authorization applies to:

Other
Special Medical Category Release

Some categories of information require explicit release. Please indicate your preference for the categories below.
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.
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.
Signature:
Date:

MonthDayYear
Date
Should be Empty:

Special Medical Category Release