Health Information Release Form

I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present my written revocation to Medical Records at the Kansas City CARE Clinic dba
KC CARE Health Center. The written revocation must be signed by the patient who provided the consent. I understand that the revocation will not apply to information that has already been released in response to this authorization. Unless
otherwise revoked or noted above, this authorization will expire one year from the date this authorization is signed.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information
to be used or disclosed, as provided in C.F.R. 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality
rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is
expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The
federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

Requests for copies of medical records or non-documented material may be subject to copying fees.