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Salina Regional Health Center Hospitals and Affiliated Clinics Authorization for Use and Disclosure of Protected Health Information

Your request may take up to 30 days to process. Most requests are completed within 2 weeks or less.

Section 1 - Please select the location(s) where you are a patient:

Cloud County Health Center

  • Family Care Center
  • Cloud County Health Center - Hospital

Comcare

  • Comcare Ohio
  • Comcare Minneapolis
  • Occupational Health Partners
  • Comcare Santa Fe
  • StatCare
  • Endocrinology

Lindsborg Community Hospital

  • Family Healthcare
  • Hospital

Memorial Health System

  • Memorial Hospital
  • Comprehensive Pain Solutions
  • Heartland Health Care Clinic

Salina Regional Health Center

  • Hospital
  • Gastroenterology
  • Heart Center
  • Neurosciences
  • Neurosurgery
  • Tammy Walker Cancer Center Oncology / Hematology
  • Orthopedic Clinic
  • Pediatric Care
  • Podiatry
  • Pulmonary, Critical Care, Sleep Medicine
  • Surgical Associates
  • Urgent Care
  • Women's Clinic
  • Other - Please specify:

Section 2 - Patient Information

**Date(s) of service:
Personal Legal Disability Continuing Care Transfer of Care Other

Section 3 - Who do you want to receive your medical records?

Fax:

Section 4 - Who has your medical records that you want to request? Where are the medical records?

Section 5 - Place an X by the medical record reports you want. Be specific. We will only send what you mark:

  • Patient name, address, insurance
  • History and physical
  • Discharge Summary
  • Consultation(s)
  • Procedure(s)
  • Progress Note(s)
  • Imaging/X-ray Reports
  • Lab test result(s)
  • Medication list
  • Immunization(s)
  • Workman comp report(s)
  • Employment exam
  • School/Sport physical
  • Physician order(s)
  • Patient billing
  • All PHI, no billing
  • All PHI, plus billing
  • Radiology film(s)
  • Other:
The following are designated as sensitive items that need special attention. Your initials are required for each box that is checked.
  • HIV/AIDS test/treatment; initial to release:
  • Sexually transmitted disease; initial to release:
  • Drug/Alcohol problem; initial to release:
  • Mental Health Information; initial to release:
  • Genetic Testing; initial to release:
  • Sexual assault; initial to release:
  • Abortion; initial to release:
  • Other:

Section 6 - Authorization

  • I understand this authorization is voluntary. If I do not sign this form, my healthcare from SRHC and the payment for this healthcare will not be affected.
  • I understand once my protected health information (PHI) is released, it may no longer be protected from federal privacy regulations. My PHI may be redisclosed without my knowledge.
  • I understand I may see and copy the information on this form if I ask for it. I will get a copy of this form after I sign it.
  • I understand my request for PHI may be refused and I will be told in writing the reason. I may be able to have a neutral person review the refusal. SRHC will do what the neutral person says after review.
  • I understand this authorization will expire on: . If blank this authorization will expire one year from the date that this form is signed.
  • This authorization may include my medical record information created within twelve months after the date this authorization is signed, or the expire date entered.
  • I understand that I may change my mind after I have signed this form. I can cancel this form any time by sending a written letter to:

    Salina Regional Health Center
    Privacy Officer
    400 S. Santa Fe
    Salina, KS 67401

    The cancellation of this authorization will not cancel any actions SRHC took before I cancelled this consent and it was received by the Privacy Officer. SRHC Privacy Practices may be accessed at www.srhc.com.
  • Please call (785) 452-7032 to talk with an ROI staff member if you need help filling out the form or have questions. Do not sign this form until it is completed.

Section 7 - Signature

Nov 27 2022