Authorization To Release Healthcare Information

Use the form below or download the pdf and fax to 989-753-8453.

Patient's Name*
First Last
Previous Name (if applicable)
First Last
Date of Birth*
Month
Day
Year
Social Security Number*
Release Information To:
I request and authorize VALLEY OB-GYN. CLINIC, P.C to release healthcare information of the patient named above to:
Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Fax
Authorization:
This request and authorization applies to:*
- Healthcare information relating to a treatment, condition, or dates
- All healthcare information
- Other
Please specify:*
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
- No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.*
- Yes
- No
Signature*
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Phone
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To make an appointment, please call 989-753-8453