AUTHORIZATION TO DISCLOSE/RELEASE OR OBTAIN MEDICAL RECORDS All disclosures are in compliance with Federal and State laws, including the Health Insurance Portability and Accountability Act of 1996 (HIPAA), governing the use and disclosure of Protected Health Information (PHI).I hereby authorize Kansas Surgical Consultants, LLP to: Disclose/Release To Obtain FromName of Person or OrganizationPhoneFaxAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information RequestedI hereby agree to this authorization and understand that it must contain Personally Identifiable Information and PHI as defined by HIPAA to ensure accuracy. I understand I have the right to limit the type of information released and to revoke this authorization by submitting a notice, in writing, to Kansas Surgical Consultants. Unless revoked, this authorization will expire one year from date of signature. If I choose to limit the information released, I understand that Kansas Surgical Consultants may inform the requestor that portions of the record have been withheld. I understand the information disclosed may be subject to re-disclosure by the recipient and no longer be protected by Kansas Surgical Consultants. Kansas Surgical Consultants and its staff are hereby released from any legal responsibility or liability for disclosure of the below information to the extent indicated and authorized herein ALL medical records without exception, including: clinical notes, lab testing (including HIV), mental health treatment, alcohol or drug abuse testing and treatment, sexually transmitted disease, consultations, secondary records, etc. PARTIAL medical records which may include HIV testing & treatment, mental health treatment, alcohol or drug abuse testing & treatment, sexually transmitted disease & other sensitive information. Please specify parts and dates to be released belowPartial Medical Records Progress Notes X-Ray Reports Lab Reports Pathology Reports Consultations Surgery/Procedure Reports Other (Please specify below)Please SpecifyIf you selected any of the options above, please specify the dates to be releasedI authorize the release of my medical records as indicated above.Signature of Patient or Guardian (Please type your name) First Last Email Date of Birth Month Day YearAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Note to Recipient: This information has been disclosed to you from records whose confidentiality is protected by Federal and State laws (including HIPAA) and prohibits you from further disclosure without the written consent of the person to whom it pertains. Charges may apply for copies of medical records.
