Dr.

Tracey Wiese, APRN

Kaitlyn Meyers, Client Navigator

Full Spectrum Health, LLC

307 E. Northern Lights Blvd, Ste 201 | Anchorage, AK 99503
Phone: 907-229-9766 | Fax: 888-974-0807 | | www.fullspectrumhealthak.com

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name: ___________________________________________ Date of Birth: ________________________

Previous Name:

I request and authorize Full Spectrum Health, LLC, including its
physicians, nurses, and other health care providers and their staff to
___(send) ____(receive) the following to:
Name: ________________________________
Address: ______________________________
Phone: ______________________________
Fax: ________________________________

This request and authorization applies to:

_________________________________________________________________________________________________

_________________________________________________________________________________________________

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.

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

Date signed:
Patient Signature: ________________

THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED AND IS NOT AFFECTED BY MY SUBSEQUENT
INCAPACITY.