Rockhill Women's Care

Release of Information Regarding the Use of Protected Health Information

I, (Patient Name)
I understand this authorization may be revoked in writing at any time unless it's already acted upon. To revoke this authorization I must send a request in writing to: Rockhill Women's Care, Inc., Attention: Medical Records, 20 NE Saint Luke's Boulevard, Suite 310 Lee's Summit, MO 64086
or within one (1) year of the date signed if I have not provided an expiration date or event.
I authorize the release of my records: (select one):

I understand that my information used or disclosed pursuant to this authorization may be re-disclosed by the recipient and would no longer be protected by the Privacy Regulations. A copy of this authorization shall be considered as effective and valid as the original.
Signature of Patient or Authorized Representative – Draw your signature below using a tablet, mouse or smartphone. By clicking the Submit button at the end of this form I understand and agree that this is a legal representation of my signature.
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