Medical Records Release
This authorization permits Topeka Allergy & Asthma Clinic to disclose/obtain your health information. Please note: A reasonable fee may be assessed for obtaining medical records, as stipulated by KS state law.
Patient Name: ___________________________________________ Date of Birth: _________________
Legal Guardian (if applicable): ____________________________________________________________
Address______________________________________ City _________________State_____ Zip_______
Disclosure authorized FROM: Disclosure authorized TO:
-Topeka Allergy & Asthma Clinic - Topeka Allergy & Asthma Clinic
- Specific Physician/Clinic - Specific Physician/Clinic/Individual:
(Provide Name/Address/Phone): Name__________________________________
_____________________________________ Phone________________ Fax_______________
Specific Medical Records/Information to be disclosed: ________________________________________
Reason/Purpose of disclosed information:
_____Patient transfer of care _____Continuation of care _____Disability Determination
_____Life Insurance _____Medical Insurance _____Legal _____Other: _______________
I authorize Topeka Allergy & Asthma Clinic to obtain/disclose the medical records or information described. I have read and understand this form. I am the patient or am the legal guardian of the patient listed.
I understand that this authorization will expire one year from the date of my signature, or until I revoke in writing at any time.
Patient/Legal Guardian Signature _____________________________________ Date _______________