360-Degree Release

360-Degree Release

Authorization to Obtain & Release Information
Client Name*
Date of Birth*

MonthDayYear
Phone Number*
Name of Partner Agency*
Client Email*
Name & Address of Medical Provider(s) if known
Name of Emergency Contact*
I authorize disclosure of information concerning my medical care and treatment for HIV and/or hepatitis C for the purpose of supporting my efforts to successfully complete treatment
Signature of Client*

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Date*

MonthDayYear
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I authorize disclosure of information concerning my medical care and treatment for HIV and/or hepatitis C for the purpose of supporting my efforts to successfully complete treatment