Authorization for UW Medicine to Use or Disclose Protected ... 2026

1. Click ‘Get Form’ to open the Authorization for Release of Immunization Information in the editor.
2. Begin by entering the Patient Name and Date of Birth in the designated fields. Ensure accuracy as this information is crucial for identification.
3. If the patient is over 18, confirm that the requester is either the patient or their personal representative. Fill in Mother's Maiden Name, Street Address, City/State/Zip next.
4. Authorize the Kansas Department of Health and Environment (KDHE) to release immunization records by filling in the Name or Organization field. Specify how you would like these records released by selecting from options such as Email, Mail, Phone Number, Fax, or In Person.
5. Complete your contact details including E-Mail Address and Fax Number if applicable. Remember that My KS Health Portal is not an option for organizations.
6. Sign and date the form at the bottom. If you are a personal representative, attach required documentation as specified.
7. Finally, return your completed form along with a copy of your government-issued ID to the provided address or via fax/email.

Start using our platform today to easily fill out and manage your authorization forms online for free!