360-Degree Release
Authorization to Obtain & Release Information
Client Name
*
Date of Birth
*
-
Month
-
Day
Year
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
*
Date
*
-
Month
-
Day
Year
Submit
Submit
Should be Empty: