[Doctor name] [Doctor name] [Doctor name] [Doctor name] [Doctor name] [Doctor name] [Doctor name]

[Street address] | [City, ST ZIP Code]

Phone: [Phone number] | Fax: [Fax number] | [Email] | [Website]

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name: [Current name]	Date of Birth: [DOB]
Previous Name: [Previous name]	Social Security #: [SSN]
I request and authorize [Authorized individual] to release healthcare information of the patient named above to:	[Name] [Street address] [City, ST ZIP Code]

This request and authorization applies to:

[List here]

[List here]

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

Patient Signature:	Date signed: [Date]

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.