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AUTHORIZATION OF RELEASE OF MEDICAL RECORDS 

Birthday
Month
Day
Year
Multi-line address

PLEASE NOTE COPY FEE MAY BE CHARGED FOR MEDICAL RECORDS 

Above listed patient authorizes the following healthcare facility to make record disclosure: 

Facility Address
Dates and Type of information to disclose:
The purpose of disclosure is:

Release to: Healthy Living First Medical Group Address: 1202 N 38th St, Kansas City, KS 66102 Fax: (913) 777-7619 Phone: (913) 777-7600 

Please Choose
Please mail records
Please fax records

  • I understand that I may revoke this authorization in writing at any time by contacting the Health Information Management Department.

  • Revocation will not apply to records already released in response to this authorization.

  • Unless otherwise specified, this authorization will expire one year from the date of signature.

  • I understand that authorizing this release is voluntary and that I may refuse to sign it without affecting my ability to receive care.

  • Released records may include information about HIV/AIDS, sexually transmitted diseases, mental health, substance abuse, or behavioral health.

  • I understand that once released, this information may not be protected by federal privacy laws. 

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