Authorization to Release Healthcare Information

Authorization to Release Healthcare Information From Your Provider to E4 Diabetes Solutions, LLC.

First Name*
Last Name*
Email*
Provider’s Name:*
Provider's Phone
Provider's Address*
Street Address Address Line 2 City State ZIP Code
I request and authorize the above provider to release healthcare information of the patient named above to: E4 Diabetes Solutions, LLC. 297 Kingsbury Grade, Suite 1044
This request and authorization applies to:*
- All healthcare information except as identified below.
I authorize VERBAL COMMUNICATION about my medical history and care to the organization listed above*
- Yes
- No
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 organization listed above. I understand that the organization listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.*
- Yes
- No
I authorize the release of any records regarding drug, alcohol, or mental health treatment to the organization listed above.*
- Yes
- No
This authorization shall continue unless I specifically revoke this authorization. This authorization is effective as of the date I first shared information with E4 Diabetes Solutions, LLC and / or the date of signature on this document, whichever is earlier. This authorization may be canceled in writing at any time. A cancellation will not change releases that happen before the cancellation.
Birthdate*
Date Format: MM slash DD slash YYYY
Signature Date*
Date Format: MM slash DD slash YYYY
Signature*
Name
This field is for validation purposes and should be left unchanged.

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