Woods & Water Medical Center

600 N 21st Street

Superior, WI 54880

AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

In an effort to avoid duplication and thereby help control costs, I hereby authorize and request

Woods & Water Medical Center

Physician or Medical Group

To release the following information contained in my records, including information about Human Immune
Deficiency Virus Positivity (HIV+), Acquired Immune Deficiency Syndrome (AIDS), and AIDS-Related
Complex (ARC), as define by the Ohio Department of Public Health.

Patient Name Date of Birth

History and Physical X-ray/MRI Report

Laboratory Reports Surgery Report
Pathology Reports Progress Report
Audiology Reports All Medical Records
Discharge Summary Treatment Summary
Other

I understand that I may revoke this authorization at any time and that it automatically expires once the
purpose for which it was intended is accomplished. My signature means that I have read this form and/or
had it read to me and explained in language that I can understand.

Signature of Patient, Parent, or Guardian Today’s Date

Woods & Water Medical Center

600 N 21st Street
Superior, WI 54880

04/02/2018