Medical Records Requests

Completing the Following Information Allows Associated Plastic Surgeons to Release or Obtain Medical Records:

    Medical Record Release Authorization

    By Completing The Following It Allows Associated Plastic Surgeons To Release My Medical Records To Myself.

    Please Send Medical Records To The Above:

    By Completing The Following It Allows Associated Plastic Surgeons To Release My Medical Records To:

    Information/Records I Would Like Disclosed/Released. Please Be As Specific As Possible.

    By Completing The Following I Am Requesting My Medical Records To Be Sent To Associated Plastic Surgeons.

    Please send requested information to Associated Plastic Surgeons – 11501 Granada Lane – Leawood KS
    66211 – Fax 913-451-5000.

    Information/Records I Would Like Sent To Associated Plastic Surgeons. Please Be Specific If Possible.

    I understand that my records may contain information regarding the diagnosis or treatment of HIV (AIDS virus). , other sexually transmitted diseases, drug and/or alcohol abuse, mental illness or psychiatric treatment. I gave my specific authorization for these records to be released. I hereby release any one, or all of you collectively, from any and all legal responsibility that may arise from the above act authorized by me. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.532. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure.

    I have read the information provided on this release form and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

    The service charges are set by the State of Kansas K.S.A. 65-4971. $18.40 for supplies and labor, plus $.61 per page for the first 250 pages, and $.44 per page thereafter.

    • We need, at minimum, your name, date of birth, and address filled out at the top of the form in order to release medical records. All sections of this authorization must be completed to be valid in accordance with 42 CFR Parts 160 and 164.
    • Fill out the “release to” section allowing us to release medical records if it’s going to another provider or entity. Please be specific with the individual or office’s name, address, phone number, and fax number to send the records to. Please be specific on how you want the record released (fax, mail, or emailed)
    • If the records are being released to yourself, then just put “Self” in the “release to” section.
    • Information that you would like to be provided should be as detailed as possible. For example please give a general time frame, date range, surgery date, or type of procedure that your wanting records from. Please provide the specific types of documents that your provider is looking for (i.e. operative reports, progress notes, test results, etc.)
    • Please physically sign the document, date it, scan it, and email it to or fax it to (913)451-5000. A handwritten signature and date is required. If a scanner or fax machine is not available, a good-quality photo of the document may be accepted for emailed requests.
    • If signed by a patient’s authorized representative, supporting legal documentation must accompany this authorization form.