PA Thrive Partnership formerly Northwest Alliance
15870 Route 322
Clarion, PA 16214
1001 State Street
Suite # 606
Erie, PA 16501
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL HIV-RELATED INFORMATION
HIV or Human Immunodeficiency Virus is the virus which causes or indicates AIDS or HIV infection. Hepatitis C (HCV) is a virus that affects the liver.
HIV/HCV - related information is information which concerns whether a client/patient has been tested for HIV, or has AIDS or an HIV- related illness, or could reasonably identify the client/patient as having one or more of these conditions.
I authorize staff, representatives, and agents of PA Thrive Partnership formerly Northwest Alliance to release and/or receive confidential HIV related information pertaining to:
The above-mentioned information is to be released and/or received only for the following purpose(s): Coordination of Care
I understand that I may revoke this consent at any time except to the extent information has already been released in reliance on this form.
This authorization must be signed and dated.
I have read and fully understood the above statements as they apply to me. I consent to the release of records/information for the purpose(s) stated above. I understand that this release will expire 1 year from date signed below.