CHATTANOOGA CENTER FOR WOMEN, PC & JACK ROWLAND, MD, PLLC 7490 Ziegler Rd. Chattanooga, TN 37421 Phone: 423.648.6020 / Fax: 423.648.6025 Gary A. Brunvoll, D.O. Sabrina Collins, M.D. Jack M. Rowland, M.D. Sarah S. Smith, DNP, CNM Katie Garrett, CNM Amy Miller-Anderson, CNM Meg Brasel, CNM Patient Name: __________________________________________________________________ First Maiden ______/_____/_______ Date of Birth Middle _______-_____-________ Social Security # Last (_______) _______-__________ Current Phone # I request and authorize the following Practice and/or facility to release my medical records to CCW or Dr. Rowland: ______________________________________________________________________________________ (Name of Dr., Hospital, Other) Address _______________________________________________________________________________________________________ City State Zip Phone: (______) _________-____________ Fax: (______) ________-___________ Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus, genital warts, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid. Lymphogranuloma venereum, HIV (Human Immunodeficiency Virus), AIDS (Acquired Immunodeficiency Syndrome) and gonorrhea. Yes No I authorize 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 the test results to anyone. Yes No I authorize the release of any records regarding drug, alcohol, or mental health treatment to the person(s) listed above. ____ Colonoscopy ____ CT Scan ____ Dexa Scan ____ Hida Scan ____ Holter Monitor ____ Labs ____ Mammogram Report ____ Operative Report ____ Pathology ____ Prenatal Records (labs, u/s’s, non-stress tests, and hospital records) ____ Ultrasound Report (for non-OB pts only) **_____ Other records i.e. financial, etc. ________________________________________________ Signature of Patient, guardian, or authorized representative ________________________ Relationship to Patient For Office Use Only: ________________________ _____________ Witness’s Signature Acct # Date ____/____/____ THIS FORM WILL EXPIRE 30 DAYS FROM THE DATE OF SIGNING