Woods & Water Medical Center

1019 South Knowles Avenue

New Richmond, WI 54017
(715) 246-6561
www.WWMC.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 contained 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 Reports

Laboratory Reports Surgery Reports
Pathology Reports Progress Reports
Audiology Reports All Medical Records
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