CONSENT FORM 

RELEASE OF MEDICAL INFORMATION 

Client Name: ____________________________________________________  

For the purposes of this form, “my” and “I” mean the patient listed above whose record is maintained by High Impacto. 

I hereby authorize High Impacto to release any and all health information that is contained in my records to other providers for treatment and as otherwise needed for my health and education at the sole discretion of High Impacto. I understand and acknowledge that this may include health information regarding HIV test results or diagnosis and treatment of AIDS/AIDS-related conditions. 

If the Authorization is not complete, signed, and dated, it may be returned and result in my information not being released until completed. 

______________________________________                     _____ / _____ / ____ 

Signature of Client                                                         Date Signed