NVDA 2026.3 with Adobe Acrobat Reader (64-bit): speech log
Document: Release of Patient Information Authorization Form – New Philadelphia City Health Department
Window title: Release of Patient Information Authorization Form – New Philadelphia City Health Department - Adobe Acrobat Reader (64-bit)
Tested: 2026-11-04. NVDA ran with its silent synthesizer; each line below is exactly what NVDA
sent to speech, one line per utterance.
Note: Adobe Acrobat Reader ran with its interface in Portuguese (Brazil), so a few words that
come from Acrobat itself are in Portuguese: "Obrigatório" = Required; "Campo de assinatura
não assinado" = Unsigned signature field; "páginas" = pages.

== When the document got focus ==
Release of Patient Information Authorization Form – New Philadelphia City Health Department - Adobe Acrobat Reader (64-bit)
unknown
document 1/1 accessible.pdf, 1 páginas
graphic page 1 New Philadelphia City Health District letterhead, with the district seal (Est. 1854). 150 E. High Avenue, St 011, New Philadelphia, OH 44663. Phone 330.364.4491 ext. 1208. Fax 330.364.8830. Website:

== Reading from the top, line by line (Ctrl+Home, then Down Arrow to the end) ==
graphic New Philadelphia City Health District letterhead, with the district seal (Est. 1854). 150 E. High Avenue, St 011, New Philadelphia, OH 44663. Phone 330.364.4491 ext. 1208. Fax 330.364.8830. Website:
graphic https://www.newphiladelphiaoh.gov/170/Health-Department
heading level 1 Release of Patient Information Authorization Form
Patient Name_____________________________________________ Date________________
Patient's full name, Obrigatório edit
Date (MM/DD/YYYY), Obrigatório edit
Date of Birth__________________________ Telephone Number_________________________
Patient's date of birth (MM/DD/YYYY), Obrigatório edit
Telephone number, with area code, Obrigatório edit
Address_______________________________________________________________________
Street address, Obrigatório edit
City____________________________________ State_________ Zip Code_________________
City, Obrigatório edit
State, Obrigatório edit
ZIP code, Obrigatório edit
To provide continuity of care, I hereby authorize
check box not checked Authorized to release information: New Philadelphia City Health Department
New Philadelphia City Health Department
check box not checked Authorized to release information: Other
Other __________________________________
Other party authorized to release information (name) edit
To release pertinent medical information related to this case to
check box not checked Release information to: New Philadelphia City Health Department
New Philadelphia City Health Department
check box not checked Release information to: Other
Other______________________________
Other party to receive the information (name) edit
Print Name________________________________ Relationship to Patient_________________
Printed name of person signing, Obrigatório edit
Relationship to patient, Obrigatório edit
Signature_________________________________________________ Date________________
Signature (Clique para assinar), Obrigatório Campo de assinatura não assinado, Obrigatório
Date signed (MM/DD/YYYY), Obrigatório edit
Witness Signature (if applicable)_______________________________ Date________________
Witness signature (if applicable) (Clique para assinar) Campo de assinatura não assinado
Date of witness signature (MM/DD/YYYY) edit
Health Department Use only
Records Requested:
check box not checked Health Department use only. Records requested: Immunization Records
Immunization Records
check box not checked Health Department use only. Records requested: Clinic Visit Notes
Clinic Visit Notes
check box not checked Health Department use only. Records requested: Other
Other________________________________
Health Department use only. Other records requested edit
check box not checked Health Department use only. Identification verified at pick up
Identification verified at pick up
Authorization and consent will expire six months from the date of authorization unless revoked by the patent or legal representative through written notice. Any revocation does not apply to information that has been previously released in response
to this authorization. DF 12/01/2025

== Headings (H key) ==
Release of Patient Information Authorization Form heading level 1
no next heading

== Graphics (G key) ==
no next graphic
no next graphic

== Form fields (Tab key) ==
Patient's full name, Obrigatório edit blank
Date (MM/DD/YYYY), Obrigatório edit blank
Patient's date of birth (MM/DD/YYYY), Obrigatório edit blank
Telephone number, with area code, Obrigatório edit blank
Street address, Obrigatório edit blank
City, Obrigatório edit blank
State, Obrigatório edit blank
ZIP code, Obrigatório edit blank
Authorized to release information: New Philadelphia City Health Department check box not checked
Authorized to release information: Other check box not checked
Other party authorized to release information (name) edit blank
Release information to: New Philadelphia City Health Department check box not checked
Release information to: Other check box not checked
Other party to receive the information (name) edit blank
Printed name of person signing, Obrigatório edit blank
Relationship to patient, Obrigatório edit blank
Campo de assinatura não assinado, Obrigatório
Date signed (MM/DD/YYYY), Obrigatório edit blank
Campo de assinatura não assinado
Date of witness signature (MM/DD/YYYY) edit blank
Health Department use only. Records requested: Immunization Records check box not checked
Health Department use only. Records requested: Clinic Visit Notes check box not checked
Health Department use only. Records requested: Other check box not checked
Health Department use only. Other records requested edit blank
Health Department use only. Identification verified at pick up check box not checked
Patient's full name, Obrigatório edit blank
