Medical Records Release

II authorize the release of the following information from the health records of:

Name

First NameLast Name

Email

example@example.com

Phone Number

Format: (000) 000-0000.

Social Security Number

Birth Date

MonthDayYear

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Information to be disclosed:

Other Records Requested:

For the Purpose of:

For the Dates of:

Enter Date Range:

Office You Are Transfer Documents TO: or FROM:

From:
Dr.
Street Address Address Line 2 City State Zip Fax

To:
Partners in Family Care
PO Box 640
200 E Peck
Moundridge, KS 67107
Phone: 620-345-6322
Fax: 620-345-6419

To:
Dr.
Street Address Address Line 2 City State Zip Fax

From:
Partners in Family Care
PO Box 640
200 E Peck
Moundridge, KS 67107
Phone: 620-345-6322
Fax: 620-345-6419

From:
Dr.
Street Address Address Line 2 City State Zip Fax

To:
Partners in Family Care
PO Box 116
101 W Gordon
Inman, KS 67456
Phone: 620-585-6416
Fax: 620-345-6419

To:
Dr.
Street Address Address Line 2 City State Zip Fax

From:
Partners in Family Care
PO Box 116
101 W Gordon
Inman, KS 67456
Phone: 620-585-6416
Fax: 620-345-6419

From:
Dr.
Street Address Address Line 2 City State Zip Fax

To:
Partners in Family Care
371 N Old Hwy 81
Hesston, KS 67062
Phone: 620-327-2314
Fax: 620-345-6419

To:
Dr.
Street Address Address Line 2 City State Zip Fax

From:
Partners in Family Care
371 N Old Hwy 81
Hesston, KS 67062
Phone: 620-327-2314
Fax: 620-345-6419

From:
Dr.
Street Address Address Line 2 City State Zip Fax

To:
Partners in Family Care
1800 E Gordon St
McPherson, KS 67460
Phone: 620-242-0404
Fax: 620-345-6419

To:
Dr.
Street Address Address Line 2 City State Zip Fax

From:
Partners in Family Care
1800 E Gordon St
McPherson, KS 67460
Phone: 620-242-0404
Fax: 620-345-6419

Federal Law requires that you read and understand the following statement:
My medical health information MAY contain any of the following:
Acquired Immunodeficiency Syndrome (AIDS) or Human Immunodeficiency Syndrome (HIV)
Behavioral or Psychiatric care
Alcohol and /or Drug Abuse treatments
I agree that any information contained in my medical record that pertains to any federally protected information is approved by me or my legal representative to release
to the above named person/facility:   Signature*

This information is to be disclosed for the purposes of continuing medical care only. The facility, its employees, officers, and physicians are hereby released from any
legal responsibility or liability for disclosure of the above information to the extent indicated and authorized herein. I understand this authorization may be revoked in
writing at any time, except that action has already been taken in reliance of this authorization.

Signature*   Date*

Relationship to patient if not self: