Authorization When Patient Requests Use or Disclosure of Protected Health Information

I hereby authorize Kansas Surgical Consultants to disclose any of the following information: Any medical treatment regarding billing issues, appointment concerns, and medical records related to my care as if I were the person calling or inquiring.

I understand I have a right to revoke the authorization in writing except to the extent Kansas Surgical Consultants has taken action or has relied on the authorization. This authorization may be revoked by my requesting revocation in writing and delivering a copy of the same to Kansas Surgical Consultants.

The information used or disclosed under the authorization may be subject to redisclosure by the recipient and no longer protected by federal privacy laws.