RECORDS RELEASE AUTHORIZATION (INCOMING PATIENTS) FORM

Please correct the errors described below.
(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

For the following patients:

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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.

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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