Authorization For The Use Or Disclosure Of Health Information

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Authorization for the Use or Disclosure of Health Information
It is important for your health information to be shared with all of your health care providers to ensure that you receive the best
care possible. The purpose of sharing your health information with your providers or supports is to assist in identifying any
follow-up medical care that may be needed.
Please allow ValueOptions of Kansas and your treatment team to share your health information with each other by signing the
release of information below, or having a person who is legally authorized to act on your behalf sign. We will only send and
receive information that pertains to your care.
Member/Individual Name:
Member/Individual ID or Social Security Number:
Member/Individual Date of Birth:
Authorization for Disclosure of Health Information
Information to Which This Authorization Applies:
I hereby authorize the parties identified below to disclose
42 CFR regarding substance abuse confidentiality
(send and receive) my health information to the other
requires as limited information be disclosed as possible,
parties identified in this document for a period of six
please only check the box(es) that apply
months.
Physical and Mental Health
ValueOptions of Kansas
All health information pertaining to any medical history,
Name - ValueOptions of Kansas
th
mental or physical condition, and treatment received
Address – 100 SE 9
St., Suite 501
(including services provided at a Community Mental
Topeka, KS 66612
Health Center and/or information related to HIV/AIDS
Phone – Toll Free - (866) 645-8216
status) in the possession, custody or control of the
Fax – (785) 338-9020
parties identified in this document, regardless of when
such information was generated. This authorization
Regional Alcohol and Drug Assessment Center (RADAC)
does not include substance abuse records.
Name ____________________________________
Substance Abuse
Address__________________________________
Phone_________________________
I specifically authorize the release of personal health
information from my drug and alcohol assessment. The
Fax___________________________
recipient of drug and/or alcohol abuse information
disclosed as a result of this Authorization will need my
Physical Health Plan/Medical Provider
further written authorization to re-disclose this
Name ____________________________________
information. 42 CFR §2.32 restricts any use of this
Address__________________________________
information to criminally investigate or prosecute any
Phone_________________________
alcohol or drug abuse patient. Initials:_____
Fax___________________________
Specific Information
The following records or types of health information
 Kansas Health Solutions (Please check the box if
(including any dates):
applicable)
Information
Date Range
Address – 534 S. Kansas Ave., Suite 510 Topeka, KS 66603
_____________________
__________________
Phone – Toll Free – 877-642-9283
_____________________
__________________
Fax – 785-232-2610
_____________________
__________________
Initials:_____ Date:________
Page 1 of 4
Revised February, 2010

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