Eric Garcia
 
  
 DIS Slidell 
 RE2170526 
 1310 Gause Blvd 
 Slidell 
 LA 70458 
 Phone: 440-770-7051
 Fax: (550) 850-5504 
 RELEASE OF INFORMATION 
 AUTHORIZATION TO USE & DISCLOSE PROTECTED HEALTH INFORMATION 
 Date 01-03-2024
 Pt ID: CIS250346 
 Acct # 
 Last Name: GARIBALDI 
 First: JUSTIN 
 MI: 
 BIRTHDATE: 12-07-1997 
 Patient Address: 208 N SILVERMAPLE DR 
 SLIDELL 
 LA 
 70508 
 Patient Phone: (504) 506-8505 
 I specifically authorize the use and/or disclosure of the following highly confidential information: Mental health, HIV results, 
 AIDS information. 
 Signature: 
 I 
 HAVE READ THE ABOVE AND AUTHORIZE THE DISCI OSURE OF THE PROTECTED HEALTH INFORMATION AS STATED: 
 Signature of Patient/Guardian/Representative 
 05-01-2015 
