Overland park regional medical center medical records 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out Section A. Enter the Patient Name, Birth Date, Provider’s Name, and Recipient’s Name. Ensure all fields are completed accurately.
3. Provide the Provider’s Address, including Address 1, City, State, and Zip Code. If applicable, include Address 2.
4. Indicate your preferred Request Delivery method: Paper Copy, Email, or USB drive/CD/DVD. If you select Email, be sure to enter a legible Email Address.
5. Specify the expiration of this authorization by filling in either a Date or an Event (not both).
6. In the Purpose of Disclosure section, describe the information you wish to be used or disclosed. If requesting psychotherapy notes, ensure only that item is checked.
7. Review and initial the acknowledgment regarding potential sensitive information contained in the release.
8. Complete Section C by signing and dating the form. If applicable, print the name of your representative and their relationship to you.

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