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Authorization for Release of Medical Information

I hereby authorize:

To provide medical information to:

Data requested:

I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, sexually transmitted diseases, drug and/or alcohol abuse, mental illness, psychiatric treatment, or genetic information. I give my specific authorization for these records to be released.

This authorization will expire within 1 year. I may revoke this authorization in writing at any time, provided that the information has not yet been released. To view the process for revoking this authorization, please read the Privacy Notice to our patients. I understand that once the Walla Walla Clinic discloses health information, the person or organization that receives it may re-disclose it, at which it may no longer be protected under privacy laws. I understand I do not have to sign this authorization in order to receive healthcare benefits.