Kansas City Psychiatric Group

Authorization For Release Of Protected Health Information

Doctor’s Office / Doctor’s Name to Release Information
This section can never be the patient’s/parent’s/spouse’s/relative’s information
Fax transmission authorized, if needed?  
Agency/Person to Receive Information
Kansas City Psychiatric Group     Phone 913-338-0400     Fax 913-338-0428
8300 College Blvd., Suite 320     Overland Park, KS 66210
Fax transmission authorized, if needed?  
This information is requested for the following purpose:  

The information I would like released is:
Treatment plan  
Office visit notes  
Form completion  
All records  
Initial evaluation  
Make and cancel appts. only
Speak freely  
Letter regarding  

Read Carefully
My signature below acknowledges my understanding of the following:
  1. I understand that medical/behavioral health records are confidential. By signing this authorization, I am allowing the release of information, including any substance abuse information, to the agency or person specified above. Transfer of the information released above to persons or agencies not specified is prohibited by law.
  2. I understand that signing this authorization is not a condition of receiving treatment here.
  3. This authorization includes both information presently compiled and information to be compiled during the client’s treatment at this agency.
  4. I understand that there is a potential for the information disclosed to be subject to re-disclosure by the recipient and no longer protected by this law.
  5. This consent is subject to revocation by the undersigned at any time by completing the notice of revocation at the bottom of the page.
  6. This consent to release information (unless revoked earlier) will automatically terminate one year from the date of signing, or twelve months from the date of signing if the purpose is for other than treatment.
  7. This authorization does not have an expiration date unless I, the patient/guardian, revokes this authorization in writing OR superseded by state or local laws.
  8. I understand that I have the right to receive a copy of this authorization and to request to see or copy the information disclosed.
  9. This authorization to release information is subject to the following restrictions:
Patient/guardian signatureDraw 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, and that I understand and agree to the above statements.
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