AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

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.

Patient's Name:

Date of Birth:

Previous Name:

Social Security #:

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

Name:

Address:

Phone#:

FAX#:

This request and authorization applies to:

Healthcare information relating to the following treatment, condition, or dates:

All healthcare information

Other:

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.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that must give specific written permission before disclosure of these test results to anyone.

Yes No

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Yes No

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient's Signature:

Date signed:

Your information will be encrypted.