Medical Release

250 MARKET ST, SAN DIEGO, CA. 92101
AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
Name *

First Name Middle Name Last Name
Birthday *

Month Day Year
Date
Last 4 of SSN
Phone Number

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
I request and authorize *
Name of either Doctor/Hospital/Medical Center
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Fax

Area Code Phone Number
Purpose *

Continued Care Personal Insurance Legal
To release healthcare information of the patient named above to:

Gaslamp Medical Center

Dr. Alfredo Quinonez

250 Market Street

San Diego, Ca. 92101

619-239-9675

619-515-1136 Fax
This request and authorization applies to: *

All healthcare information Healthcare information relating to the following treatment, condition, or dates
List below information to be released if 2nd box checked above
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. *
Signature *

Clear
Date *

Month Day Year
Date
Should be Empty:

250 MARKET ST, SAN DIEGO, CA. 92101

AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION