Medical Release Form - Ashewell Medical Group

Patient’s Name(Required)

(and any previously used names)

Date of Birth(Required)

Social Security Number(Required)

I request and authorize my former healthcare provider to release healthcare information pertaining to the patient named above to Carly Brown MD, Anna Bartow, MD, Ananda Vieages, MD, and Ashewell Medical Group, 408 Depot St., Suite 150, Asheville, NC 28801

Former Healthcare Provider Name(Required)

Facility Name(Required)

Fax Number(Required)

We are requesting:

Notes

Labs

Imaging

Other:

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.(Required)

Yes

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 any records regarding drug, alcohol, or mental health treatment to the person(s) listed above(Required)

Yes

Patient Signature(Required)

Date(Required)

THIS FORM EXPIRES 1 YEAR FROM THE DATE OF SIGNATURE.

Name

This field is for validation purposes and should be left unchanged.