Chfs legibly kentucky online 2025

1. Click ‘Get Form’ to open the chfs legibly kentucky online document in the editor.
2. Begin by filling in your personal information in the 'Individual Requesting Records' section. Ensure you print your name, address, city, state, zip code, and telephone number clearly.
3. Next, provide the details of where you want the records sent. Fill in the recipient's name and address accurately, including both home and work telephone numbers if applicable.
4. Indicate the name of the individual whose information is being disclosed along with their Social Security Number and Date of Birth. If known, include the Case Record Number and County where it is maintained.
5. Specify the purpose for disclosure in the designated field. This step is crucial; do not leave it blank.
6. Select which specific Protected Health Information (PHI) you authorize for disclosure by checking all relevant boxes provided on the form.
7. Finally, read through the authorization statement carefully before signing and dating at the bottom of the form to confirm your understanding and consent.

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