(IS ANYONE OTHER THAN YOU AUTHORIZED TO REQUEST YOUR HEALTH INFORMATION-SUCH AS A FRIEND OR FAMILY MEMBER)
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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):
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.
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