"*" indicates required fields 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 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: Client / Patient Name: Date of Birth: The type of information that is to be released/received: HIV specific treatment information Office notes Lab studies Imaging/radiology results Medication list Hospital summaries Mental Health treatment STD treatment Select AllThe information is to be released and/or received from/to: (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. Date: Client/Patient Signature Date: Witness Signature Signature of Person Authorized in lieu of Client/Patient Relationship to Client/Patient Consent* I agree that the information provided on this form is complete and accurate, and PA Thrive Partnership can use this digital form as a legally binding authorization for release of confidential HIV-related information.