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Authorization Form For Disclosure Of Protected Health Information - Kansas
| Authorization Form For Disclosure Of Protected Health Information Form. This is a Kansas form and can be used in Civil 3rd Judicial District (Shawnee County) Local District Court . |
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F 3.201(2)F AUTHORIZATION FORM FOR DISCLOSURE OF PROTECTED HEALTH INFORMATION Instructions: All of the Blocks 1 - 6 must be completed. If any block is not completed then this Authorization Form will be considered incomplete and defective and cannot be used. PLEASE PRINT ALL INFORM ATION EXCEPT FOR REQU IRED SIGNATURE S.Block 1: Identification of Patient PATIENT NAM E: ________________________________________________ DATE OF BIRT H: _____________________PATIENT S ADDRESS: ________________________________________________________________________________ Street [Apt. number, P.O. box - as applicable] , City, State & zip code.SOCIAL SECURITY NUM BER or OTHER IDENT IFIER: ________________________________________________Block 2: Type of Records / Information to be Disclosed----CHEC K ONLY ONE OF THE FOLLOW ING BOXES (A or B). Ifneither box is checked or if both boxes are checked then this form will be considered defective and cannot be used. IF YOUW ANT BOTH TYPES OF RECO RDS D ISCLOSED YOU MU ST US E TW O SEPARAT E FORM S - One for Each Purpose. 9 A. Records except for Psychotherapy Notes 9 B. Psychotherapy Notes only.DESCR IBE WHAT S PECI FIC RECO RDS MAY BE DISCLOS ED (examples: All records, X-Rays only, records for last 12months) AND/OR CHE CK ALL THAT APPL Y: 9 All Records* 9 alcohol/drug evaluation or treatment 9 HIV/Aids Status____________________________________________________________________________________________________________________________________________________________________________________________________________* All includes inpatient/outpatient records, medical, dental, psychiatric, alcohol/chemical/substance abuse, HIV/Aids, pharmaceutical, hospital orphysician records, office notes, narrative summaries, telephone messages, correspondence to/from/about me, diagnostic testing results, bills,statements & invoices whether or not you created those records as long as the records are in your control or possession.Block 3: Persons, facility, or class of persons who are authorized to disclose (provide) the records / informati on:______________________________________________________________________________________________________________________________________________________________________________________________________________Block 4: Persons, facility, or class of persons who are authorized to receive the records / informati on:_______________________________________________________________________________________________________and his/her/its attorneys, agents, staff, representatives, experts or other designated person by them/it.Block 5: Expirat ion: This Authorization will expire on ___________________(M M /DD/YY)[cannot exceed 1 year from datebelow] or on the following specific event: _____________________________________________________________________Block 6: Authorizing Signature This request for disclosure of medical records/information is made at my request for the purpose of legal proceedings. 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 also understand that certain records may be protected by federal or state law and I am requesting that any and all such protected records be released under this authorization. I also understand that I may revoke this authorization at any time by delivering/mailing a written revocation to the party or attorney or law firm named in Block 4 above. If I revoke this authorization it will have no effect on actions already taken on reliance on this form. The covered entity will not condition treatment, payment, enrollment or eligibility for benefits on whether the individual signs the authorization. I authorize the disclosure of the records/information described. I have read and understand this form. I am the patient listed or am authorized to act on behalf of the patient as the patients personal representative. I also permit disclosure of the records upon presentation of a photocopy of this authorization. _________________________________________________________ __________________________________Signature of Patient (or Patients Personal Representative, if applicable) Date of SignaturePersonal Representatives Relationship / Capacity to Patient:____________________________________________________Printed Name of Personal Representative: ____________________________________________________________________Printed address & telephone number of Personal Representative: __________________________________________________ Revised: October 2002
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