MPC Medical Records Release

Manhattan Primary Care

Bradley K. Harrison MD, FAAFP Kerri Maxcy PA-C Kyle Platz DO
AUTHORIZATION FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient Name:*
Date of Birth:*

MonthDayYear
Date
SS#:
Phone Number*
Please enter a valid phone number.
Address*

Address

Street Address Line 2

CityState

Postal / Zip Code
Zip Code*
I, the undersigned, hereby authorize disclosure of information FROM: *
HAS your records and will be SENDING records
Disclose records TO: *
NEEDS your records and will be RECEIVING records
Other Office:

Self   Other (please complete all contact info below)*

Office Name/ Provider

Street Address   Address Line 2   City   State   Zip
Area Code   Phone Number
Area Code   Fax Number
Manhattan Primary Care 1133 College Ave, Ste A211, Manhattan, KS 66502 Phone: 785-320-5000 Fax: 1-888-524-2251
Obtain/Release the following written information:

Please select all that apply
Complete health record
All Records from Date toDate
Verbal communication of treatment and discuss relevant concerns
All Records from    Date to Date
X-rays from   Date to   Date
Labs from   Date   to   Date
Other     from Date to Date
Purpose of Disclosure:
Consultation with Transfer of care
Insurance coverage Personal access
I authorize the release of my personal health information that may be related to substance abuse, mental health, HIV/AIDS or infectious disease, and records protected by state and federal laws related to a minor.**

I Understand
Substance abuse (alcohol or drug information)
Mental Health Information
HIV related information (AIDS related testing)
Information protected by state and federal laws related to a minor
Patient/Guardian or Legal Representative Signature:

Clear
Date

MonthDayYear
Date
This authorization will expire on the following date or event, unless revoked in writing, effective for no longer than one year from the date on which it was signed.*

I Understand
Set expiration date:

MonthDayYear
Optional
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.
Patient/Guardian or Legal Representative Signature:*

Clear
Date*

MonthDayYear
Date
Relationship to Patient:*
Manhattan Primary Care 1133 College Ave, Suite A211; Manhattan, KS 66502-2770 Phone 785-320-5000 Fax 1-888-524-2251 www.ManhattanKSPrimaryCare.com
Should be Empty:

Manhattan Primary Care

Other Office:

Office Name/ Provider

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

Obtain/Release the following written information: