Continuum Healthcare Release Of Medical Information
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1Continuum Healthcare Release of Medical Information
Permission to get records
I, ___________________________, with a date of birth, ________________, give my permission for
(Patient Name)
(Patients DOB)
_______________________________ to give my medical records described below to
(Doctor’s/hospital name who has records)
_______________________________ so that he/she can better understand my condition and help me.
(Name of Doctor requesting medical records)
Permission to get sensitive information
By putting my initials by each item below, I understand that I give permission for records to be sent that may contain
information about:
_____________ my mental health
_____________ transmittable disease I may have like HIV/AIDS
_____________ Genetic records
_____________ Drug and alcohol records
Consent for release of medical records for _____________________________________________________
(Patient Name and Date of Birth)
Requesting records from
Name of Practice:
Name of Physician:
Fax Number:
Address:
Type of records we are requesting
☐Any and all types of records you have for this patient
☐Doctor visit notes
☐Operation or procedure notes
☐Nurses Notes
☐Emergency Room notes
☐Clinic Notes
☐Discharge Summary
☐Urgent care notes
☐Clinic Notes
☐Lab reports
☐History and Physical
☐Pathology Reports
☐Radiology Reports
☐Hospital Progress Notes
☐Doctor orders
☐Other
_______________________
Records within the following dates
Records dated between
☐All records for this patient
____________________and____________________
Please send all records to:
Continuum Healthcare, 11661 College Blvd, Overland Park, KS
Fax to 913-432-8402
If you have any question please call us at 913-432-8400
I understand that:
I do not have to give my permission to share these records
If I want to take away the permission for my doctor to get these records, I need to talk to my doctor
or a staff person and sign a paper.
This form is only good for 3 months from the date I signed it
Patient Signature:
Date:
Authorized Representative’s Signature
Date:
Relationship of Authorized Representative:
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