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PA Thrive Partnership formerly Northwest Alliance

15870 Route 322
Suite #2
Clarion, PA 16214
Phone: 814-297-8220
Fax: 814-297-8379

1001 State Street
Suite # 606
Erie, PA 16501
Phone: 814-454-3811
Fax: 814-454-3422


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 type of information that is to be released/received:
(Name of organization or individual who is to be given information)

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.