JCPH Release of Information Form

Patient Name:*

Date of Birth:*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Telephone:*

I am Requesting my protected health information (PHI) from:*

JCPH - 3651 NE Ralph Powell Rd, Lee's Summit, MO 64064

Name:*

Address*

Street Address

CityState / Province

Postal / Zip Code

Fax (if healthcare provider):

I authorize the following PHI to be release from my medical records:*

Laboratory ReportsOther

Covering the periods of healthcare from:*

Date

To*

Date

Purpose of requesting information:*

Delivery method:*

US Mail (paper)FaxEmail (not secure)Front Desk

If requesting email delivery method:

example@example.com

By signing this authorization form, I understand that:

PHI may include records relating to mental health care, communicable disease, HIV/AIDS, and/or treatment of alcohol/drug abuse I have the right to revoke this authorization at any time. Revocation must be made in writing and presented to the Release of Information department. Revocation will not apply to any information that has already been released in response to this authorization.
Unless otherwise revoked, this authorization shall expire within six months of the date signed
Treatment, payment, enrollment or eligibility for benefits may not be conditioned on whether I sign this authorization
Any disclosure of information carries with it the potential for unauthorized re-disclosures, and the information may not be protected by federal confidentiality rules
If the page count of my request is fifty-one (51) pages or greater, I understand that I will only be able to obtain my records in an electronic format (flash drive, email or CD)

Patient/Authorized Representative Signature:*

Date:*

The dates covered by this request will be the beginning date listed above, through the date this authorization is signed

Printed Name of Authorized Requestor:*

Relationship to Patient:*

(Legal Guardian, mother, self, etc.)

Please provide a valid picture ID of the person authorizing this release.*

PROHIBITION ON DISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulations (42 CFR Part 2) prohibits you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose. You have the right to view and receive copies of certain portions of your medical & financial records kept by Truman Medical Centers or our business associates. You may not view or receive copies of any psychotherapy notes as that term is defined in 45 C.F.R. Sec. 164.501, information restricted under the Clinical Laboratory Improvements Amendments of 1988 (42 U.S.C. § 263a), and certain other records Truman Medical Centers complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-816-404-3280 (TTY: 1-816-404-0002)

o 1-816-404-3280 (TTY: 1-816-404-0002)

I request my PHI be released to: