Rittenhouse Women's Wellness Center

Available Forms

A.) Internal Medicine Authorization to Release Healthcare Information A.) Internal Medicine Health History Form A.) Internal Medicine HIPAA : Notice of Privacy Practices A.) Patient Registration B.) Dermacenter Client Information and History C.) Nutrition 3 Day Food Diary C.) Nutrition History D.) Dr. Perilstein: Emotional Well-being Authorization to Release Protected Health Information D.) Dr. Perilstein: Emotional Wellbeing Consent for Treatment D.) Dr. Perilstein: Emotional Wellbeing Receipt of Privacy Information E.) Dr. Liggera's Patient Registration Form F.) Payment and Cancellation Policy G.) Email Agreement

A.) Internal Medicine Authorization to Release Healthcare Information

Authorization to Release Records

Name

Last, First, MI

Date of Birth

(MM/DD/YYYY)

Previous Name

Social Security #

I request and authorize (physician and/or practice listed below) to release healthcare information of the patient named above to: Rittenhouse Women's Wellness Center, 1632 Pine Street, Philadelphia, PA, 19103

Physician/Practice name, address, and phone/fax number

The request and authorization applies to:

Healthcare information relating to the treatment, condition, or dates listed in box

All healthcare information

Other (describe in box below)

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, syphillis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficieny Syndrome) and gonorrhea.

I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person(s) listed above. I understand that the person(s) listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.

yes

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above.

Yes

Patient Signature and Date Signed

By typing name above you are herby authorizing Your records to be transferred.<br/>THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.

* Required field