AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Please correct the errors described below.

This form authorizes PrimeCare of Coral Gables to obtain your medical records from your previous and/or other healthcare providers. Accessing these medical records will improve the quality and continuity of your healthcare and avoid the unnecessary and costly repetition of medical tests.

I request and authorize PrimeCare of Coral Gables to release healthcare information of the patient named above to:

This request and authorization applies to:

All healthcare information

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, venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome), and gonorrhea.

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