Get Ks Es 3904 2017-2025

Completing the KS ES 3904 form online is essential for authorizing the disclosure of medical and educational records. This guide will help you navigate each section of the form with ease and confidence.

Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to obtain the form and open it in your desired editor.
2. Begin by entering your Social Security Number (SSN) at the top of the form. This information is needed to identify your records accurately.
3. Fill in your first name, middle name, and last name in the designated fields to ensure correct identification.
4. Enter your date of birth using the format mm/dd/yy to provide your age and assist in identifying your records.
5. Read the authorization statement carefully. This disclosure permission includes all your medical and educational records that relate to your ability to perform tasks.
6. In the section regarding the source of information to be disclosed, list all medical and psychological sources, including any educational records that may help in evaluation.
7. Indicate the purpose of disclosure. This is typically for determining your eligibility for medical assistance.
8. Review the expiration date for the authorization, which typically lasts 12 months from the date you sign the form.
9. Authorize the disclosure by signing the form. Provide your street address, phone number, city, state (KS), and ZIP code.
10. If necessary, a witness should sign the form if you use an 'X' to sign your name.
11. Once all sections are complete, save your changes. You may then choose to download, print, or share the completed form as needed.

Complete your KS ES 3904 form online now to ensure your information is processed efficiently.