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Authorization Release Healthcare Information

This Authorization expires 90 days after it is signed
- Patient’s Full Name*
- Previous Name
- Patient’s Date of Birth
  MM slash DD slash YYYY
- Social Security #
- I request and authorize
- I request and authorize*
- to release healthcare information of the patient named above to
- BioIntelligent Wellness, 7220 Avenida Encinas 110-B, Carlsbad, CA 92009
  Phone: 858 228 3644, Fax: 760 994 1248, E-mail: [email protected]
- Healthcare information relating to the following treatment, condition, or dates
  - Healthcare information relating to the following treatment, condition, or dates
- List
  Please Specify Treatment/Condition? Please Specify Date?
- All healthcare information
  - All healthcare information
- Other
  - Other
- List
  Please Specify Treatment/Condition? Please Specify Date?
- 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
- This request and authorization applies to
  - 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*
  MM slash DD slash YYYY
Date
MM slash DD slash YYYY

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Carlsbad

7220 Avenida Encinas, Suite 110-B
Carlsbad, CA 92011

Working hours

Office hours :

Weekdays 8:00 am to 5:00 pm
Saturday 8:00 am to 1:00 pm

Coaching Hours:

Weekdays 6:00 am to 7:00 pm
Saturday 8:00 am to 2:00 pm

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Office/Scheduling: 858 228 3644
Fax: 858-228-3641
E-mail: [email protected]

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  Friday 9:30am to 2:00pm
  
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  Saturday 9:30am to 2:00pm
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Please Specify Treatment/Condition?	Please Specify Date?

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Authorization Release Healthcare Information

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