Woods & Water Medical Center

1019 S Knowles Avenue

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

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

______________________________________________________________________________
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: Darwin Brown Date of Birth

6/7/1983
History and Physical X-ray/MRI-Reports
Laboratory Reports Surgery Report
x Pathology Reports Progress Report
x Audiology Reports x All Medical Records
Discharge Summary Treatment Summary
Others

To: Stanley Leonard, MD

Address: 233 North Smith Ave
Madison, WI 55731

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 a language that I can
understand.

Signature of Patient, Parent, or Guardian Today’s Date: 4/3/2024