Authorization to Release Healthcare Information

Authorization to Release Healthcare Information

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

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:

2. All healthcare information

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.

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