Woods & Water Medical Center

1019 S. Knowles Avenue • New Richmond, WI • 54017 • 715.246.6561 • www.wwcm@world.com

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

In an effort to avoid duplication, and thereby help control costs, I hereby authorize and request

Physician or Medical Group

To release the following information in my records, including information about Human Immune Deficiency Virus
Positivity, (HIV+), Acquired Immune Deficiency syndrome (AIDS), and AIDS-Related Complex (ARC), as defined by
the Ohio Department of Public Health.

Patient Name Date of Birth

History and Physical X-ray/MRI Report

Laboratory Reports Surgery Report
Pathology Reports Progress Report
Audiology Reports All Medical Reports
Discharge Summary Treatment Summary
Other

To:

I understand that I may revoke this authorization at any time and that it automatically expires once the purpose
for which it was intended is accomplished. My signature means that I have read this form and/or have had it read
to me and explained in language that I can understand.

Signature of Patient, Parent, or Guardian Today’s Date

April 14, 2019