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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.

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Patient Name: ___________________________________________ Date of Birth: _________________

Legal Guardian (if applicable): ____________________________________________________________

Address______________________________________ City _________________State_____ Zip_______

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   Disclosure authorized FROM:                                               Disclosure authorized TO:

    -Topeka Allergy & Asthma Clinic                                                - Topeka Allergy & Asthma Clinic                   

     TO:                                                                                        FROM:

     - Specific Physician/Clinic                                                      - Specific Physician/Clinic/Individual:            

    (Provide Name/Address/Phone):                                                 Name__________________________________

    _____________________________________                                   Address________________________________

    _____________________________________                                   City________________________State_______              

     _____________________________________                                    Zip________________

     _____________________________________                                 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 _______________