Authorization for Disclosure of Medical Record Information

Authorization for Disclosure of Medical Recdord Information
A fee for copying medical records may be assessed to the requester. Please check with the medical records clerk. Request may take up to 30 days to fullfill. Failure to complete any portion of this request, may result in denial of the request.
You must attach a copy of valid photo ID, including signature, of the individual requesting records (drivers license, passport, state issued ID or other valid picture ID). Failure to complete this step may result in denial of your request.

Browse Files

Cancelof
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Format: (000) 000-0000.
Medical Record # (if you know it)
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState

Zip Code
RELEASE INFORMATION FROM

Other
RELEASE INFORMATION TO

Other
Dates Covered
PLEASE SPECIFY TYPE OF INFORMATION TO BE RELEASED

Other
PURPOSE FOR WHICH INFORMATION IS TO BE USED:

Other
AUTHORIZATION: I certify that this request has been made voluntarily and that the information given is accurate to the best of my knowledge. If this authorization applies to treatment for any of the following condition(s), please check
- I understand that I may revoke this authorization at any time, except to the extent that action has already been taken to comply with it. Written revocation shall be submitted to the Privacy Officer or designee.
- This authorization will automatically expire 180 days from date of signature.
- Information disclosed may be subject to redisclosure by the recipient and no longer be protected by state or federal law or regulations
- Any photostatic of this authorization shall be as effective as any orginal signed by me
- I will not be prohibited any future benefits, including treatment, payment or eligibility thereof from said provider by refusing to sign this authorization
Signature: Patient &/or Representative
If other than the patient indicate relationship:

Other
For Medical Records Use Only

Released by_________________________Date_____________Pages_______
Kimball Health Services

255 W. 4th STREET, KIMBALL, NE 69145-1313 308-235-1952

Fax 308-235-1955 Hospital | Fax 308-235-2403
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Authorization for Disclosure of Medical Recdord Information