Get Ks Kdhe Authorization For Release Of Immunization Information 2021-2025

The KS KDHE Authorization For Release Of Immunization Information is an essential form for individuals seeking to obtain immunization records. This guide will walk you through the process of completing this form online, ensuring clarity and ease.

Follow the steps to complete the form accurately and efficiently.

1. Press the ‘Get Form’ button to access the authorization form. This will open the form in your online editor for completion.
2. Fill in the patient name and date of birth in the designated fields. Ensure that the information matches official records.
3. If the patient is over 18 years old, confirm that the requester is either the patient or their personal representative. Include the patient's mother's maiden name for security verification.
4. Input the street address, city, state, and zip code of the patient to ensure accurate identification and contact.
5. Authorize the Kansas Department of Health and Environment (KDHE) to release all relevant immunization records. Clearly indicate the recipient's name or organization along with their preferred method of release (mail, email, fax, in person, or the My KS Health Portal).
6. Specify the type of immunization record you are requesting by selecting between all immunizations, Covid-19 only, or both.
7. Provide your contact information, including phone number and email address. If using fax, include the fax number as well.
8. Sign and date the form, ensuring that your printed name and relationship to the patient (if applicable) are clearly noted.
9. If you are the personal representative, attach the required documentation supporting your status, such as a court appointment or health care proxy.
10. Return the completed form along with a copy of your government-issued identification to the appropriate KDHE address via mail, fax, or email as specified in the instructions.
11. Finally, save your changes, and consider downloading or printing a copy of the form for your records. You may also share it with relevant parties if necessary.

Complete your documentation online to ensure prompt processing of your immunization information request.