Maine law requires our practice to inform you that, if this information is misused, disclosing your HIV infection status may have consequences, such as negative treatment in your personal life or by insurance companies. It can be important for providing you needed services and healthcare.
My specific permission is required to disclose information regarding HIV Test Results or Status. I understand that authorizing the release of such information does not confirm the existence of such history or treatment. Check one of the two options below and initial at end to confirm your choice
33 Sewall Street
Portland, ME 04102
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