This form authorizes the release of plaintiff's confidential medical records to plaintiff's attorney.
Kentucky Authorization to Release Confidential Records
State:
Multi-State
Control #:
US-PI-0312
Format:
Word;
Rich Text
Instant download
Description
How to fill out Authorization To Release Confidential Records?
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FAQ
Example, if your provider maintains paper medical records, they own and have the right to keep the original record, but you have the right to see and get a copy of it.
Providers and Hospitals: Medical records shall be retained for at least six (6) years from date of discharge, or three (3) years after the patient reaches the age of majority under state law, whichever is the longest.
You may submit a letter identifying the records sought or complete and submit a Division of Health Care - Open Records Request Form. Please be sure to provide your name, address and daytime telephone number in the event we need to contact you. All requests for records must be signed by the requester.
This form should include specific details such as the person or organization being authorized, the person or organization being sent the information, the nature of the information being shared, the reason for the disclosure of information, and important statements that the patient needs to understand before they sign.
You may submit a letter identifying the records sought or complete and submit a Division of Health Care - Open Records Request Form. Please be sure to provide your name, address and daytime telephone number in the event we need to contact you. All requests for records must be signed by the requester.
(1) Upon a patient's written request, a hospital licensed under KRS Chapter 216B or a health care provider shall provide, without charge to the patient, a copy of the patient's medical record.
A Privacy Rule Authorization is an individual's signed permission to allow a covered entity to use or disclose the individual's protected health information (PHI) that is described in the Authorization for the purpose(s) and to the recipient(s) stated in the Authorization.
