Authorization for Disclosure of Medical Record Information

Authorization for Disclosure of Medical Redord Information
A fee for coping medical records may be assessed to the requester. Please check with the medical records clerk. Request may take up to 30 days to fullfill. Failure to complete any portion of this requiest, may result in denial of the request.
You must attach a copy of valid photo ID, including signature, of the individual requesting records (drivers license, passport, state issued ID or other valid picture ID). Failure to complete this step may result in denial of your request.

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Cancelof
Date

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Medical Record # (if you know it)
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip Code
RELEASE INFORMATION FROM*

Kimball Health Services Hospital RecordsKimball Health Services Clinic(s) RecordsOther
RELEASE INFORMATION TO*

Kimball Health Services Hospital RecordsKimball Health Services Clinic(s) RecordsPick up in personOther
Dates Covered*
PLEASE SPECIFY TYPE OF INFORMATION TO BE RELEASED*

History & PhysicalDischarge SummaryOperative NotesConsultationsEmergency Room ReportProgress BitesDismissal InstructionsRadiology ReportsSocial HistoryLab ResultsHome HealthOther
PURPOSE FOR WHICH INFORMATION IS TO BE USED:*

TreatmentInsurancePersonalFollow-upLegal ProceedingsOther
AUTHORIZATION: I certify that this request has been voluntarily and that the information given is accurate to the best of my knowledge. If this authorization applies to treatment for any of the following condition(s), please check

Chemical Dependency or AbuseAlcoholism or Alcohol AbuseInfection with Human Immunodeficiency Virus (HIV)Sickle Cell AnemiaMental Health Records
- I understand that I may revoke this authorization at any time, except to extent that action has already been taken to comply with it. Written revocation shall be submitted to the Privacy Officer or designee.
- This authorization will automatically expire 180 days from date of signature.
- Information disclosed may be subject to redisclosure by the recipient and no longer be protected by state or federal law or regulations
- Any photostacic of this authorization shall be as effective as any orginal signed by me
- I will not be prohibited any future benefits, including treatment, payment or eligibility thereof from said provider by refusing to sign this authorization
Signature: Patient &/or Representative*

Clear
If other than the patient indicate relationship:

ParentSpouseGuardian/Personal RepresentativeOther
For Medical Records Use Only

Released by_________________________Date_____________Pages_______
Kimball Health Services

255 W. 4th STREET, KIMBALL, NE 69145-1313 308-235-1952

Fax 308-235-1955 Hospital | Fax 308-235-2403
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Authorization for Disclosure of Medical Redord Information