Form

First Name
Your First Name
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M.I
Your M.I
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Last Name
Your Last Name
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Address:
Your Address
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Zipcode:
Zipcode
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Telephone
Your Telephone
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City:
City
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Cell Phone:
Your Cell Phone
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Email Address
Your Email Address
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Whom should we contact in case of emergency
Enter Name
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Telephone number of that Person
Telephone number
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Relation
Relation
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Email address:
Email Address
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Authorization to Release Healthcare Information

Subject’s Name
Subject’s Name
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Previous Name ( if applicable)
Subject’s Name
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Subject’s Date of Birth
Select a date
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I request and authorize:(Dr/Facility)
Dr.
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Request and authorization applies to all healthcare information unless otherwise excluded by  The patient 

Request and authorization applies to all healthcare information unless otherwise excluded by  The patient 

Exclusion
Exclusion
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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, non­specific 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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 I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.
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Signature:
I, hereby , give authorization by way of electronic signature to release all medical records as herein   Described.  Additionally, I authorize Helix Biomedics, LLC to add me to their database. Unless, I herein opt  out by writing info@gfr.wxt.mybluehost.me
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