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Health Information Release Form
Patient Name
*
First
Last
Date of Birth
*
MM slash DD slash YYYY
Phone
*
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
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Armed Forces Americas
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State
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*
Release covers the dates of service from
*
MM slash DD slash YYYY
to
*
MM slash DD slash YYYY
Please check all of the boxes that you want to have released
*
I authorize the following information to be released from my medical or dental record(s) and/or shared with the person or organization designated below:
Discharge Summary
Consultation
Laboratory Report
HIV Related Information
Behavioral/Psychiatric
Alcohol / Drug Treatment
Radiology Report
Entire Record
Progress Notes
History & Physical
Office Notes
Other
Please Specify
*
Reason for requesting information:
*
Legal
Continuation of Care
Personal
Insurance
Other
Please specify
*
Send my protected health information to, or share with:
Name
*
First
Last
Organization
*
Phone
*
Fax
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Request my protected health information from:
Name
*
First
Last
Phone
*
Fax
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Patient signature required.
*
If the patient is under 18 years old, a guardian’s signature is required.
Patient Consent
*
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.
I agree
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