Get Ks Kdhe Authorization For Release Of Immunization Information 2017-2025

Filling out the KS KDHE Authorization For Release Of Immunization Information is a straightforward process that enables users to authorize the release of their immunization records. This guide will provide you with clear, step-by-step instructions for completing the form online to ensure your request is handled effectively.

Follow the steps to complete the authorization form effectively.

1. Use the ‘Get Form’ button to access the authorization form online.
2. Enter the patient’s name and date of birth in the designated fields to properly identify the individual whose records you are requesting.
3. For patients over 18 years of age, ensure that the request is made by the patient or their personal representative, and fill in the requesting party's relationship to the patient in the provided field.
4. Complete the mother's maiden name, street address, city, state, and ZIP code to provide accurate contact information.
5. Specify the name or organization to which the records should be sent and enter their corresponding street address, city, state, and ZIP code.
6. Select the method you prefer for the release of information from the options provided: e-mail, mail, phone number, fax, or in person. Note that using the My KS Health Portal is not available for organizations.
7. If applicable, enter the e-mail address and fax number for the organization or individual receiving the records.
8. Review the expiration statement regarding the authorization, noting that it will auto-expire one year from the date signed.
9. Print the name, provide the signature of the patient or personal representative, indicate their relationship to the patient, and date the document.
10. If applicable, attach any required documentation specific to the personal representative and ensure the appropriate identification is included.
11. Submit the completed form, along with a government-issued identification copy, to the specified address via mail, fax, or email as outlined in the instructions.

Complete your authorization for the release of immunization information online today.