At Speedy Template, You can download Authorization to Release Healthcare Information . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
[Street Address], [City, ST ZIP Code]
Phone: [Phone Number] Fax: [Fax Number]
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
Date of Birth:
Social Security #:
I request and authorize
release healthcare information of the patient named above to:
This request and authorization applies to:
!Healthcare information relating to the following treatment, condition, or dates:
!All healthcare information
Definition:Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes
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