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Insurance Authorization - Kansas

Insurance Authorization Form. This is a Kansas form and can be used in Civil 3rd Judicial District (Shawnee County) Local District Court .
 Fillable pdf Last Modified 4/30/2009
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INSURANCE AUTHORIZATION TO: Re: S.S.No.: Date of Birth:The undersigned hereby authorizes you to disclose and furnish to the law office of __________________________________________________________________________________________________ ____________________all facts and information pertaining to my insurance coverage, including all records concerning history, medicaltreatment, any insurance communications, insurance claim forms, records of payment, and any other records in your filepertaining to my insurance coverage. These attorneys are to have full a nd complete access to any and all of these recordsand also any further information gained through a business relationship while I was covered by your insurance policy.I understand that my medical records (including STD, HIV, chemical depe ndency, psychiatric and/or pharmaceuticalrecords) may be protected by federal and/or state regulations. I hereb y authorize said attorneys to redisclose copies ofsaid records and/or information contained therein to other persons, firm s and corporations for purposes connected with apending lawsuit in which I and said attorneys are involved. The undersigned further states that photostatic copies of this authoriza tion shall have the full force and effect of theoriginal. This authorization shall remain effective for a period of one year from the date on which it has been executedunless you receive notification from the undersigned to the contrary.Executed this _________ day of ________________________, 20_____. ___________________________________ (Name) ____________________________________ (Address) ____________________________________STATE OF _____________________ ) ) ss: COUNTY OF ___________________ ) On this _________ day of ________________________, 20______, before me personally appeared__________________________________, to me known to be the person describ ed herein and who executed theforegoing instrument and acknowledged that s/he voluntarily executed the same. _____________________________________ Notary PublicMy Appointment Expires: _______________________
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