AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Patient’s Name:

Date of Birth:

Previous name (if applicable):

I request and authorize REIS PEDIATRICS to release healthcare information to (for example, if you want your parent or guardian to have access to your records or be able to call our office on your behalf, list their name below):

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:

Please specify treatment/condition including dates:

All healthcare information

Other:

Please specify:

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.

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

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient Name:

Date:

Your information will be encrypted.