graphic: kids

Is Your Child Sick?TM

Visual Symptom Checker

Emergencies

Medical Emergency:
Poison Control:

Office After Hours:
Call 911
(800) 222-1222

(808) 524-2575

Records Release

I authorize

(previous physician and
phone number and fax number)

to release protected health information to

REIS PEDIATRICS
30 Aulike Street, Suite 500
Kailua, HI 96734
808-263-8822
Fax 808-261-6749

Check One



Other:

For the following patients:










This Authorization will expire 360 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.