Release Form

Consent-Release-Information

Consent to Release Information To/From*

Who you would like to have access to your medical information.
Patient Name*
I consent for Kentucky Mental Health Care (KMHC) to release my (or my dependent’s) personal healthcare information (PHI) to requesting third party organizations, including, but not limited to: the social security administration (SSA) and other government entities, medical offices, mental health offices, and attorneys. I understand that PHI is considered every page of my (or my dependent’s) electronic health record file, including, but not limited to: intake forms, progress notes, treatment plans, itemized bills, assessments, file uploads, and discharge paperwork. I understand that there is a potential for disclosure of this information by the third-party recipient and if that occurs, federal law may not protect the information and KMHC is not liable.
Notes*
Please put the facility’s fax number, name, and what specific records you would like us to release/them to release to us.
Client Signature*
Parent/Guardian must sign if client is a minor
Date*
DD slash MM slash YYYY
Right of Revocation

I understand that I have the right to revoke this authorization at any time by sending written notice (address below) to Kentucky Mental Health Care, LLC. I understand that a revocation is not valid to the extent that Kentucky Mental Health Care, LLC has acted in reliance on such authorization. This authorization does not expire until I submit a written request. A hard or digital copy of this release shall have the same force and effect as the original.
Client Signature*
Parent/Guardian must sign if client is a minor
Date*
DD slash MM slash YYYY
Notice to Receiving Provider or Organization

You may not re-disclose any of this information unless the individual who consented to this disclosure specifically consents in writing to such re-disclosure
Corporate Mailing Address

Kentucky Mental Health Care | 5115 S. 3rd Street | Louisville, KY 40214

Release Form

Consent-Release-Information

Right of Revocation

Notice to Receiving Provider or Organization

Corporate Mailing Address

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