• 250 MARKET ST, SAN DIEGO, CA. 92101

  • AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION

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  • 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

  • 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.

  • Clear
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  • Should be Empty: