Palm Beach Hello Health	Rosalia Leite-Evans MD

745 US 1
Suite 203

North Palm Beach, FL 33408

PH: 561-247-0825

Fax: 561-491-2305

pbhh@gmail.com

www.palmbeachhellohealth.com

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name: [Current name]	Date of Birth: [DOB]
Previous Name: [Previous name]	Social Security #: [SSN]
I request and authorize [Authorized individual] [facility/provider address] [facility/provider fax] to release healthcare information of the patient named above to:	Rosalia Leite-Evans MD 745 US 1 Suite 203 North Palm Beach, FL 33408

This request and authorization applies to:

[List here]

[List here]

[Additional information]

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 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.
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Patient Signature:	Date signed: [Date]

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.