Authorization for Release of Medical Record Information

Patient Name*

First and Last Name

Date of Birth*

Date

Primary Phone*

Work Phone*

If not work phone, put Primary Phone Number

Address*

Address

Street Address Line 2

City, State, Zip Code

Please Note: A search fee and a copy fee of $0.10 per page may be charged for Medical Records

Above listed patient authorizes the following healthcare facility to make record disclosure:

Facility Name*

Facility Phone*

Facility Address*

Facility Fax*

If none, put "none"

City, State, Zip Code*

Dates and Type of Information to Disclose:*

2 years prior from last date seenSpecific Information RequestedDates Other

Specify Other Dates:

Purpose of Disclosure is:*

Change of Insurance or PhysicianContinuation of CareReferralOther

Specify Other:

Restrictions: Only medical records originated through this healthcare facility will be copied unless otherwise requested. This authorization is valid only for the release of medical information dated prior to and including the date on this authorization unless other dates are specified.

I understand the information in my health record may include information lated to sexually transmitted disease, acquired immunodeficiency syndrome (AIDs), or human immunodeficiency virus (HIV). It may also include information about behavior or mental health service, and treatment for alcohol and drug abuse

This information may be disclosed and used by the following individual or organization:

Release to: Platte County Health Department

Address: 7925 NW 110th Street, Kansas City, MO 64153

Phone: 816.858.2412

Fax: 816.858.2087

Please send this information via*

Mail RecordsFax Records

I understand I may 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 the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition:

If I fail to specificy an expiration date, event, or condition, this authorization will expire one (1) year from the date 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 CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure 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.

I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

Signature*

Clear

Date*

Date

Printed Name of Authorized Representative*

Relationship/Capacity to Patient*

Address and Phone Number of Authorized Representative*