Medical Record Release Authorization____________________________________________________________________________________________________________Patient name:Birth Date:

Maiden name:Social Security #:Patient Address:
City:

State:

Zip Code:Home phone:
Cell:
Work:
____________________________________________________________________________________________________________I hereby authorize records FROM:

To be released TO:

Facility or Physician:Andover Family Medicine

Address:2117 N. Keystone Circle

City/State/Zip:

Andover, KS 67002

Phone:
Fax:
Phone (316) 733-5120
Fax (316) 733-1280____________________________________________________________________________________________________________Purpose of the request:
Transfer or Continuity of Care

Self/Personal Copy

Insurance

Litigation

DisabilityWork Comp
Other:____________________________________________________________________________________________________________Records requested:
What specific records may be disclosed:

Date Range:

toPhysician Office Notes
Lab/Pathology Reports
Immunizations_______ Radiology/X-Ray/MRI Reports
Cardiology/EKG Reports
Entire Record_______ Operative/Procedure Reports
ER Reports____________________________________________________________________________________________________________Expiration
This authorization will expire one year from the date below unless I specify an earlier expiration date:____________________________________________________________________________________________________________Statement of Understanding
I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I
need not sign this form in order to assure treatment. I understand that any disclosure of information carries with it the potential for an
unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about
disclosure of my health information, I can contact the authorized individual or organization making disclosure.
I understand that the information in my medical record may include information relating to sexually transmitted disease,acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about
behavioral or mental health services, and treatment for alcohol and drug abuse.
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must
do so in writing. I understand that the revocation will not apply to information that has already been released in response to thisauthorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with theright to contest a claim under my policy.
I am the patient listed or I am authorized to act on behalf of the patient as the patient’s personal representative.

Signature of Patient/Legal Representative:Printed Name:

Date:
Relationship:*We reserve the right to charge the medical record state fee structure as set forth in the state statute.*____________________________________________________________________________________________________________