II authorize the release of the following information from the health records of:
From:Dr. Street Address Address Line 2 City State Zip Fax To:Partners in Family CarePO Box 640200 E PeckMoundridge, KS 67107Phone: 620-345-6322Fax: 620-345-6419
To:Dr. Street Address Address Line 2 City State Zip Fax From:Partners in Family CarePO Box 640200 E PeckMoundridge, KS 67107Phone: 620-345-6322Fax: 620-345-6419
From:Dr. Street Address Address Line 2 City State Zip Fax To:Partners in Family CarePO Box 116101 W GordonInman, KS 67456Phone: 620-585-6416Fax: 620-345-6419
To:Dr. Street Address Address Line 2 City State Zip Fax From:Partners in Family CarePO Box 116101 W GordonInman, KS 67456Phone: 620-585-6416Fax: 620-345-6419
From:Dr. Street Address Address Line 2 City State Zip Fax To:Partners in Family Care371 N Old Hwy 81Hesston, KS 67062Phone: 620-327-2314Fax: 620-345-6419
To:Dr. Street Address Address Line 2 City State Zip Fax From:Partners in Family Care371 N Old Hwy 81Hesston, KS 67062Phone: 620-327-2314Fax: 620-345-6419
From:Dr. Street Address Address Line 2 City State Zip Fax To:Partners in Family Care1800 E Gordon StMcPherson, KS 67460Phone: 620-242-0404Fax: 620-345-6419
To:Dr. Street Address Address Line 2 City State Zip Fax From:Partners in Family Care1800 E Gordon StMcPherson, KS 67460Phone: 620-242-0404Fax: 620-345-6419
Federal Law requires that you read and understand the following statement:My medical health information MAY contain any of the following:Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Syndrome (HIV)Behavioral or Psychiatric careAlcohol and /or Drug Abuse treatmentsI agree that any information contained in my medical record that pertains to any federally protected information is approved by me or my legal representative to releaseto the above named person/facility: Signature* This information is to be disclosed for the purposes of continuing medical care only. The facility, its employees, officers, and physicians are hereby released from anylegal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand this authorization may be revoked inwriting at any time, except that action has already been taken in reliance of this authorization.Signature* Date* Relationship to patient if not self: