Christopher Howard
 
  
 DIS Slidell 
 RE2170526 
 1310 Gause Blvd 
 Slidell 
 LA 70458 
 Phone: 619-528-3007
 Fax: (511) 811-5114 
 RELEASE OF INFORMATION 
 AUTHORIZATION TO USE & DISCLOSE PROTECTED HEALTH INFORMATION 
 Date 16/06/24
 Pt ID: CIS211346 
 Acct # 
 Last Name: GARIBALDI 
 First: JUSTIN 
 MI: 
 date of birth: 90/09/28 
 Patient Address: 208 N SILVERMAPLE DR 
 SLIDELL 
 LA 
 70118 
 Patient Phone: (504) 116-8115 
 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 
 17/01/07 
