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The document is a HIPAA-compliant authorization form allowing the Kansas Department of Health & Environment (KDHE) to disclose an individual's medical, educational, and psychological records. It specifies the types of information to be shared, including details about impairments affecting task performance and work ability. The authorization is valid for 12 months and can be revoked at any time. It outlines the purpose of the disclosure as determining eligibility for medical assistance.

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Versions	Form popularity	Fillable & printable
2017	4.7 Satisfied (59 Votes)

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