Authorization to Release Healthcare Information From E4 Diabetes Solutions, LLC, to Youngberg Lifestyle Medicine Clinic
Provider’s Name:
E4 Diabetes Solutions, LLC.
297 Kingsbury Grade, Suite 1044
I request and authorize the above provider to release healthcare information of the patient named above to:
Youngberg Lifestyle Medicine Clinic 28780 Single Oak Dr. Suite 243 Temecula, CA 9259
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
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.
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.
◻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.
