C_1 Blank Medical Release Authorization

AVIDA HOME CARE & Lifting Our Neighborhood

790 N. Milwaukee #355, Milwaukee, WI 53202 888-207-9870
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS
Patient Information
Client Full Name*
Client Address*
Client Date of Birth*

MonthDayYear
Date
Client Phone Number*
Format: (000) 000-0000.
I, the undersigned, hereby authorize the facility and/or provider:
Primary Care Physician Name or Clinic Name*
Clinic Phone Number*
Format: (000) 000-0000.
Clinic Address*
Clinic Fax*

to release my medical records to:

Avida Home Care/LONN 790 N. Milwaukee #355, Milwaukee, WI 53202 888-207-9870 | Fax: 866-550-1342 info@avidahealth.org
All Healthcare InformationHealthcare information relating to the following treatment, condition or dates: __________Other
Healthcare information relating to the following treatment, condition or dates (leave blank to include all relevant medical information)*

MonthDayYear
Date
Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papillomavirus, wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereum, 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 listed above. I understand that the person 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 listed above.
Patient Signature*
Date Signed*

MonthDayYear
Date
Confidential Notice: This message (including any attachments) is intended for the sole use of the individual and the entity to whom it is addressed. This message may contain confidential information protected by law, including the Privacy Act of 1974 and the Health Insurance Portability and Accountability Act (HIPAA If you are not the intended recipient, you are hereby notified that any disclosure, copying, or distribution of this message is strictly prohibited. If you received this message in error, please immediately notify the sender and delete the message.

Release of Medical Information
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Patient Information