Authorization for Release of Protected Health Information - KDHE - kdheks 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in your client name and ID or SSN at the top of the form. This information is crucial for identifying your health records.
3. In the authorization section, clearly state your name to authorize the use or disclosure of your health information.
4. Specify the person or organization authorized to provide your information in section 1. Be as detailed as possible to ensure clarity.
5. In section 2, indicate who is authorized to receive and use this information. This could be a specific individual or an organization.
6. Provide a meaningful description of the information you wish to disclose in section 3, including relevant dates and types of documents.
7. State the purpose of your request in section 4. If you prefer not to specify, simply write 'At the request of the individual.'
8. Review sections regarding revocation rights and expiration dates carefully before signing at the bottom of the form.

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