NOW OFFERING Behavioral Health Services

Ashewell Medical Group

Medical Release Form

(and any previously used names)
MM slash DD slash YYYY

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

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)
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)

MM slash DD slash YYYY
This field is for validation purposes and should be left unchanged.