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Authorization to Release Healthcare Information

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


Patient’s Name:		Date of Birth:
Previous Name (if applicable):

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

City:

State:

Zip Code:

Relation:

Phone number:

This request and authorization applies to (check one please):
	Healthcare information relating to the following treatment or condition including dates:
	All healthcare information:

	Other:
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.:	Yes No
I authorize the release of any records regarding drugs, alcohol, or mental health treatment to the person listed above.:	Yes No

Patient Name:

Signature:

Date:

30 Aulike St, Suite 500, Kailua, HI 96734 • 808-263-8822

Privacy Statement

RemedyConnect, Inc. has created this privacy statement in order to demonstrate our firm commitment to your privacy. The following discloses our information gathering and dissemination practices for this website: http://www.remedyconnect.com.

Acquisition of Information through PMD

We do not acquire any more information about website visitors than is required by law or is otherwise necessary to provide a high level of service efficiently and securely. Our site's registration form requires users to give us contact information (e.g., their name and e-mail address) and demographic information (e.g., children's birth months, but not birth dates). We use customer contact information from the registration form to (1) send the user pertinent medical and parenting information and (2) allow your local health provider lists of who is registering on that provider's site as a parent/guardian, staff member, doctor, or visitor. Users may opt-out of receiving future mailings; see the choice/opt-out section below.

We use your IP address to help diagnose problems with our server and to administer our Website. Your IP address is used to help identify you and to gather broad demographic information.

Demographic and profile data is also collected at our site. We may use this data to tailor the visitor's experience at our site, showing them content that we think they might be interested in, and displaying the content according to their preferences.

Our site may use order forms to allow users to request information, products, and services.

Your Doctor's Right to Privacy

We will respect your doctor's right to privacy. A doctor typically does not give his/her e-mail address to the parents/guardians of patients. We will not provide the e-mail addresses of doctor(s) in the local practice to users of their site without the doctor(s)' permission. Their site is restricted to use by whomever they wish, and they may deny access to their site to one or more prior users. In unusual cases, doctors may change their private site's access code and arrange for us to e-mail the new access code to approved users.

Cookies

We use cookies to deliver content specific to your interests and to save your doctor's access code so you don't have to re-enter it each time you visit your doctor's site on http://www.remedyconnect.com.

Links

This site contains links to other sites. RemedyConnect.com is not responsible for the privacy practices or the content of such Websites. See Disclaimers.

Disclosure to Third Parties

We will provide individually-identifiable information about website users to third parties only if we are compelled to do so by order of a duly-empowered governmental authority, we have the express permission of the visitor, or it is necessary to process transactions and provide you services from our affiliates: Live Agent Answering Service, Digital Answering Service, Medical Answering Service and Pediatric Answering Service.

Privacy and Our Business Partners

When we make our technology or services available to business partners, we will not share with them any more consumer information than is necessary, and we will make every reasonable effort to assure, by contract or otherwise, that they use our technology and services in a manner that is consistent with this Privacy Policy.

Public Forums

This site may make chat rooms, forums, message boards, and/or news groups available to its users. Please remember that any information that is disclosed in these areas becomes public information and you should exercise caution when deciding to disclose your personal information.

Security

This site has security measures in place to protect the loss, misuse and alteration of the information under our control. For further information regarding our security, please contact us at support@remedyconnect.com. If you have any concerns regarding the security of information, please do not provide any information to RemedyConnect, Inc. until you are comfortable with our security measures.

Correct/Update

You may correct or update your User Registration information at any time, by visiting the User Registration section and providing your personal password that you set at registration. If need be, please email us at support@remedyconnect.com.

Choice/Opt-Out

Our site provides users the opportunity to opt-out of receiving e-mail communications from our partners or us, except communications approved by your doctor's practice office. To so opt-out, please email us at support@remedyconnect.com. To be removed as a user, please email us at the same address. If need be, you may mail requests to us at RemedyConnect, Inc.

Contacting the Website

If you have any questions about this privacy statement, the practices of this site, or your dealings with this Website, you can contact us by email at support@remedyconnect.com or by mail at our address above.

Privacy

In This Section

Is Your Child Sick?TM

Medical Advice and Tips

Emergencies

Authorization to Release Healthcare Information

Is Your Child Sick?^TM