RECORDS RELEASE AUTHORIZATION (OUTGOING PATIENTS)

Please correct the errors described below.

I AUTHORIZE REIS PEDIATRICS TO RELEASE PROTECTED HEALTH INFORMATION TO:

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 your protected health information. Also, please be aware that once we disclose this information per your instructions, the information is subject to re-disclosure andmay no longer be protected.

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