(IS ANYONE OTHER THAN YOU AUTHORIZED TO REQUEST YOUR HEALTH INFORMATION-SUCH AS A FRIEND OR FAMILY MEMBER)
Please correct the errors described below.
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.
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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.