Authorization For Release Of Protected Health Information
Client name
Date of birth
Person making request
Relationship
Doctor’s Office / Doctor’s Name to
Release
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?
Yes
No
Agency/Person to
Receive
Information
Ex: Dr.’s office/name, law office, disability determinations, employer, family member, OR “Self” if patient requesting
Name
Phone
Fax
Address
City
State
Zip
Fax transmission authorized, if needed?
Yes
No
This information is requested for the following purpose:
Continuity of care
Application/reapplication for benefits
Disability determination
Legal proceedings
Other
Please specify
The information I would like released is:
Yes
No
Medications
Yes
No
Treatment plan
Yes
No
Office visit notes
Yes
No
Form completion
Yes
No
All records
Yes
No
Initial evaluation
Yes
No
Labs
Yes
No
Payments/billing
Yes
No
Make and cancel appts. only
Yes
No
Speak freely
Yes
No
Letter regarding
Please include details
Yes
No
Other
Please describe
Written information only
Verbal information only
Written and verbal information
Read Carefully
My signature below acknowledges my understanding of the following:
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.
I understand that signing this authorization is not a condition of receiving treatment here.
This authorization includes both information presently compiled and information to be compiled during the client’s treatment at this agency.
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.
This consent is subject to revocation by the undersigned at any time by completing the notice of revocation at the bottom of the page.
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.
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authorization does not have an expiration date unless I, the patient/guardian, revokes this authorization in writing OR superseded by state or local laws.
I understand that I have the right to receive a copy of this authorization and to request to see or copy the information disclosed.
This authorization to release information is subject to the following restrictions:
Patient/guardian signature
–
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, and that I understand and agree to the above statements.
Patient/guardian name
Date
Witness name
Date