Authorization for the Release of Protected Health Information (PHI)

Patient Name (Print): ___________________________________________ Date of Birth: _____/_____/______

Address______________________________________________ Phone # ______________________________ I authorize Community Health Center of Southeast Kansas, Inc. (CHC/SEK) to

Release my protected health information (PHI) to; and/or Receive my protected health information (PHI) from

Name of Person/Facility Mercy Health System (“Mercy”) __________________________________________________________________________________________ I request the following PHI to be released:

Complete medical record: Includes ALL DATES for: Radiology Reports, Immunization records, Billing

records, and LAST TWO (2) YEARS only for: Office Visit Notes, Lab Reports, Medication Record, Dental Records

Complete medical record (for dates specified below)

Release of information for the period of healthcare from: As specified above in “Complete medical record” Past Year Two Years All dates Specific Dates (Month/Date/Year): _____/_____/________ to _____/_____/________

By signing this authorization, I understand that:

PHI released may include information relating to mental health care, communicable diseases, HIV/AIDS,

and/or treatment of alcohol/drug abuse. I authorize the release of these records.

I have the right to revoke this authorization at any time. Revocation must be made in writing and

presented to CHC/SEK’s Medical Records Department, 3015 N. Michigan, Pittsburg, Kansas 66762.

Revocation will not apply to information that has already been released in response to this authorization.

This authorization will expire one (1) year after the date signed below or _____(M)/_____(D)/________(Y).

Treatment, payment, enrollment or eligibility for benefits may not be and is not conditioned on whether I

sign this authorization.

I understand that the information used or disclosed by CHC/SEK under this authorization may be at risk for

re-disclosure by the recipient and may no longer be protected by federal law or state law.

Questions about the disclosure of my health information can be explained by contacting CHC/SEK’s

Medical Records Department at the contact information listed.

I am stating that I have read and understand this authorization, and any questions I have about this

authorization have been answered.

I am stating that I am the patient listed or am authorized to act on behalf of the patient as the patient’s

representative.

I am stating that I permit disclosure of the records upon the presentation of a photocopy of this

authorization.

Patient/Authorized Representative Signature: ____________________________________________________

Name of Authorized Representative (Print): ______________________________________________________

Relationship to Patient: ______________________________ Date (Month/Day/Year): _____/_____/________

(If signed by authorized representative, supporting legal documentation must accompany the authorization.)

Witness: __________________________________________ Date (Month/Day/Year): _____/_____/________

Thank you for choosing Community Health Center of Southeast Kansas, Inc. (CHC/SEK) for your healthcare needs. Please note that all information provided by you will be kept strictly confidential in compliance with Federal privacy laws. If you have any questions or need assistance, please ask the receptionist or call 620-231-9873. Please complete this form in ink. PATIENT INFORMATION Full Legal Name (Print)

Last Name: First Name: Middle Name:

Mailing Address_________________________________________ City _____________________________ State______________ Zip Code_____________ E-Mail Address___________________________________ Home Number_________________ Cell Phone________________ Work Phone_________________ Preferred method of communication for appointment reminders: Text Phone Call Date of Birth___________________ Male Female Social Security Number_______________________

Do you want to access your medical records electronically? Yes No (If yes, you will receive an email, at the email address listed above, from CHC/SEK with your log-in information and the log-in URL.) Marital Status: Employment Status: Student Status: If you are Homeless, are you: Divorced Active Duty Military Full-time Student On the Street Married Full-time Employment Part-time Student Doubling Up Partner Part-time Employment Not in School In Transitional Housing Single Self-Employed Veteran: In a Shelter Widowed Retired Yes Other Legally Separated Unemployed No RESPONSIBLE CAREGIVER (Children under 18 years of age OR Adults with Durable Power of Attorney) (Children under 18 years of age, please list two Responsible Caregivers) Name:____________________________________ Name:____________________________________ Date of Birth: ______________________________ Date of Birth: ______________________________ Social Security Number: ______________________ Social Security Number: ______________________ Relationship to the Patient:___________________ Relationship to the Patient:___________________ Mailing Address: ____________________________ Mailing Address: ____________________________ City, State, Zip: _____________________________ City, State, Zip: _____________________________

(If Responsible Caregiver(s) is a foster parent or out-of-home placement, immediately produce appropriate paperwork illustrating placement and appropriate paperwork illustrating who maintains authority to make medical decisions on the patient’s behalf).

Please Complete the Back of Form

Revised 05/2018

EMERGENCY CONTACT In the event of an emergency, who should we contact? ____________________________________________ Relationship?___________________________ Home Number _______________ Cell Phone_________________ Work Phone __________________

FINANCIAL INFORMATION (Please fill-out to help determine if you are eligible for medical discounts) Persons In Family/Household: 1 2 3 4 5 6 7 8 Other__________ Estimated Annual Family/Household Income:_____________________ INSURANCE INFORMATION Check all that apply: No Health Insurance (Patient navigators are available to help determine if you are eligible for medical discounts or coverage) KanCare (Amerigroup, Sunflower, United HealthCare) Commercial Insurance Other Medicaid Medicare Medicare Supplement Motor Vehicle Accident Workers Compensation Other Accident Provide insurance information below. Please provide the front desk with your insurance card for billing purposes.

Primary Insurance

Insurance Plan______________________________ Member ID Number _________________________ Group Number _____________________________ Policy Holder Information: Full Name ________________________________ Date of Birth ______________________________ Social Security Number _____________________ Relationship to Patient ______________________ Employer _________________________________

Secondary Insurance

Insurance Plan______________________________ Member ID Number _________________________ Group Number _____________________________ Policy Holder Information: Full Name _________________________________ Date of Birth _______________________________ Social Security Number ______________________ Relationship to Patient _______________________ Employer _________________________________

Race: American Indian/Alaskan White Native Hawaiian Pacific Islander Black or African American Asian Other Race Ethnicity: Preferred Language: Hispanic/Latino English Other ______________ Not Hispanic/Latino Spanish Have you or has anyone in your household worked in agriculture, such as planting, cultivating, or harvesting (fruits, vegetables, grains, or dairy) in the last two (2) years as a: Not Applicable Seasonal Worker Migrant Worker

Pharmacy:___________________________________ _________________________________ Name City & State

**Apothecare, physically located inside CHC/SEK’s Pittsburg and Iola clinics, is CHCSEK’s preferred pharmacy.