Authorization to Release Healthcare Information

Please complete to release all past healthcare information to Core Health.

First Name

Last Name

Date of Birth:

Social Security #

I request and authorize:

to release healthcare information of the patient named above to:
Core Health Provide Services
2131 Kingston Court
Suite 108
Marietta, GA 30067

This request and authorization applies to:

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

2. All healthcare information

3. Other:

Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, 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 I must give specific written permission before disclosure of these test results to anyone.

Yes

Patient Signature

Date

Guardian Signature

Date