graphic: kids

Is Your Child Sick?TM

Visual Symptom Checker

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Authorization to Release Healthcare Information

(is anyone other than you authorized to request your health information—such as a friend or family member.)





I request and authorize REIS PEDIATRICS to release healthcare information of the patient named above to:











This request and authorization applies to (check one please):



Definition: Sexually Transmitted Disease (STD) as defined by law, RCW 70.24 et seq., includes herpes, herpes simplex, human papilloma virus wart, genital wart, condyloma, Chlamydia, non-specific urethritis, syphilis, VDRL, chancroid, lymphogranuloma venereuem, HIV (Human Immunodeficiency Virus), AIDS, and gonorrhea.

* Please circle one:
I authorize the release of my STD results, HIV/AIDS testing, whether negative or positive, to the person listed above. I understand that the person listed above will be notified that I must give specific written permission before disclosure of these test results to anyone.:


I authorize the release of any records regarding drugs, alcohol, or mental health treatment to the person listed above.: