AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

(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):

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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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