RECORDS RELEASE AUTHORIZATION (INCOMING PATIENTS) FORM

Previous Physician Name:

Phone Number:

Fax Number:

Address:

I authorize,

(previous physician and phone number and fax number)

to release protected health to release protected health information to:
REIS PEDIATRICS
30 Aulike Street, Suite 500
Kailua, HI 96734
808-263-8822
Fax 808-261-6749

PLEASE CHECK ONE:

Please send immunization, growth, well visits and development information only. Please send a copy of the entire chart. Please send immunization records only.

For the following patients:

Child name:

Date of birth:

Add new row

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.

Parent’s name:

Address:

Phone number:

Date:

This Authorization will expire 90 days after the date identified above. You can cancel this authorization at any time, but you must do so in writing. If you cancel it, the people authorized to use and disclose your protected health information may use the information collected prior to the date you revoked this authorization. Please send written revocation to the individual or department who you authorized to use you protected health information. Also, please be aware that once we disclose this information per your instructions, the information is subject to re-disclosure and may no longer be protected.

NOTE: WHEN THIS FORM IS COMPLETED, PLEASE DO NOT SEND IT TO REIS PEDIATRICS. MAIL THIS FORM TO YOUR PREVIOUS DOCTOR TO HAVE THE RECORDS COPIED AND SENT TO OUR OFFICE. THANK YOU.

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