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

Patient-Provider Agreement (18 Years And Older)




I have read and understand the following documents that were given to me to review. I understand that these documents can be found on Reis Pediatrics website.

1. Patient-Provider Agreement
2. HIPPA Patient Acknowledgement
3. Patient Financial Responsibility
4. Medicare Lifetime Authorization
5. Insurance Authorization
6. Medical Treatment Authorization

By checking this box I agree to digitally sign this agreement.

As required by the Affordable Care Act, we have been asked to collect the following information for the federal government. Please circle one answer from each question: