• In addition to the general authorization to release records to the persons or entities listed above, I authorize the release of the records described as the following:
    including records of testing, diagnosis, or treatment of HIV, HIV related illness, AIDS, AIDS related diseases
    slides, xrays, videotapes, photographs
    (Please check all that apply)
  • Confidential notice:The document accompanying this release contain confidential information belonging to the sender. This information is legally privileged and intended for the use of the individual named above, if you are not the intended recipient, please notify the sender and dispose of the information received. Use of this protected information by anyone other than the recipient is strictly prohibited. This request will expire 90 days from signature date.