I understand that my express consent is required for you to release information relating to sexually transmitted disease, mental illness, and/or drug/alcohol abuse, pursuant to Washington Law RCW 70.24 ET. SEQ.
If I have been tested, treated, or diagnosed in connection with any sexually transmitted disease, or drug/alcohol abuse, and/or mental illness, you are specifically authorized to release to the person or entity named above all information or medical records relating to such diagnosis, testing or treatment, unless specifically excluded above.
MY RIGHTS: I understand I do not have to sign this authorization in order to obtain health care benefits (treatment, payment or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization, please read the Privacy Notice to patients posted at the facility where your information is being released. I understand that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization may re-disclose it, at which time it may no longer be protected under Privacy laws.