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Kentucky Physician s Medical Release Form 2026
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- Click ‘Get Form’ to open the Physician’s Medical Release Form in the editor.
- Begin by entering the applicant's NAME and DATE OF BIRTH in the designated fields. Ensure accuracy as this information is crucial for identification.
- Input the SOCIAL SECURITY NUMBER (SSN#) in the appropriate field. This is necessary for record-keeping and verification purposes.
- Review the list of essential physical tasks and check any contraindications that apply to the individual. This will help determine their ability to participate in physical ability testing.
- Select one of the options regarding contraindications by checking either 'There are no contraindications' or 'There are contraindications.'
- Finally, have the physician, physician assistant, or nurse practitioner sign and date the form at the bottom. Ensure that their printed name is also included for clarity.
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This form should be used when release of a patients protected health information is being made to anyone for a purpose other than treatment, payment or health
You may print the authorization form and mail or fax it. Complete the PDF form found at the link below: Authorization for Release of Information (PDF, Call us