Authorizations and Releases

Hospital/Medical Center Authorizations

PDF icon KU Medical Release
PDF icon Wesley Medical Center
PDF icon Veteran's Affairs (VA Hospital)
PDF icon University of Kansas (KU) Hospital
PDF icon St. Catherine Hospital
PDF icon Salina Regional Health Center
PDF icon Newton Medical Center
PDF icon Neuman Regional Hospital
PDF icon Kansas Heart Hospital.pdf
PDF icon Hays Medical Center
PDF icon Flint Hills Community Health Center

Substance Abuse Center of Kansas (SACK)

PDF icon Authorization to Release and/or Receive Confidential Information

Social Security Administration

PDF icon Request for Earnings (Form SSA-7050)
PDF icon ssa-3288(consent for release of info).pdf

Missouri Department of Social Services

PDF icon Individual's Request for Access to Protected Health Information.pdf
PDF icon Authorization for Release of NON-Medical Records By/To Children's Division
PDF icon Authorization for Release of Medical/Health Information

Military

PDF icon Request Pertaining to Military Records

Kansas Department of Labor

PDF icon Request for Disclosure of Tax/Benefit Information

Kansas Department of Corrections (KDOC)

PDF icon KDOC Release of Medical Records
PDF icon KDOC Release of Jail Records

Kansas Department of Children and Families (formerly SRS)

PDF icon Authorization for Release of Confidential Information

Kansas Driver's License and Title Registration

PDF icon Kansas Department of Revenue Form

Internal Revenue Service (IRS)

PDF icon Request for Copy of Tax Return (Form 4506)

General Authorizations/Releases

PDF icon Via Christi Hospitals (St. Francis, St. Joseph, St. Teresa, and Behavioral Health)
PDF icon HIPAA Authorization for Release of Information
PDF icon General Authorization for Release of Information

Drug/Alcohol and Mental Health Treatment Authorizations

PDF icon WRC Release.pdf
PDF icon Valeo Behavioral Health/Recovery Center Authorization
PDF icon Sumner Mental Health Center
PDF icon River Park Psychology Services
PDF icon Rainbow Mental Health Facility
PDF icon Prairie View Behavioral and Mental Healthcare
PDF icon Osawatomie State Hospital
PDF icon Mental Health Center of East Central Kansas-Revised.pdf
PDF icon Larned State Hospital
PDF icon Compass Behavioral Health
PDF icon COMCARE of Wichita
PDF icon Behavioral Medicine Specialists

Bureau of Prisons (BOP)

PDF icon BOP Release of Information Consent Form
PDF icon BOP Medical Release Form