Patheous Health Medical History Form

Consent for Release of Medical Information

Please complete the information below to request medical information. If you have any questions please call 913.359.6021.
Name of person requesting report/video*

First NameLast Name
Patient name*

First NameLast Name
Patient date of birth*

MonthDayYear
Location of service*

Facility Name

Street Address

CityState / Province

Postal / Zip Code
I am requesting a copy of the following

FEES reportMBS reportPhysicians History and Physical Report (MBS only)Email link to digital image video fileOther

Name of person and title to receive information *
Address of organization to receive information*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I am requesting this information to be released for the following purpose:*

Continued CareInsurance ClaimPersonal UseOther
How report is to be sent:*

FaxEmailMail
Email*
example@example.com
Fax*

Area CodePhone Number
Address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I understand that this information shall be in effect for 180 days following the date of signature. However, I understand that this authorization may be revoked at any time by giving verbal or written notice to Patheous Health, Inc. A photocopy of this authorization shall constitute a valid authorization. I understand that once my records have been released, Patheous Health, Inc. cannot retrieve them and has no control over the use of the already-released copies.

I hereby release Patheous Health, Inc. from any and all liability which may arise as a result of my authorized release of records.
Patient (or legal representative)*
Patient (or legal representative) Signature*
Date*

MonthDayYear
Date
Relationship to patient*
Witness (First and Last Name)*
Reason Patient is Unable to Sign :*

Patient No Longer at FacilityDeceasedN/AOther
If other, please explain:
Should be Empty:

Consent for Release of Medical Information