• Manhattan Primary Care

    Manhattan Primary Care

    Bradley K. Harrison MD, FAAFP Kerri Maxcy PA-C Kyle Platz DO
  • AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION

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  • Manhattan Primary Care 1133 College Ave, Ste A211, Manhattan, KS 66502 Phone: 785-320-5000 Fax: 1-888-524-2251

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  • Purpose of Disclosure:
            
          

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  •  I understand that if the person or entity that receives the described records/information is not a health care provider or health plan covered by federal privacy regulations, the records/information may be redisclosed and no longer protected by those regulations. I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, by giving written notice to Manhattan Primary Care, LLC. I understand that I have the right to inspect the information to be disclosed upon the proper notification to and under the appropriate conditions established by Manhattan Primary Care, LLC. The covered entity will not condition treatment, payment, enrollment, or eligibility for benefits on whether the individual signs the authorization. The facility, its employees and physicians are hereby released from any legal responsibility or liability for disclosure of the above information
    to the extent indicated and authorized herein.

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  • Manhattan Primary Care 1133 College Ave, Suite A211; Manhattan, KS 66502-2770 Phone 785-320-5000 Fax 1-888-524-2251 www.ManhattanKSPrimaryCare.com

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