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:

Comcare

Lindsborg Community Hospital

Family Healthcare
Hospital

Memorial Health System

Memorial Hospital
Comprehensive Pain Solutions
Heartland Health Care Clinic

North Central Kansas Medical Center

Family Care Center
North Central Kansas Medical Center - Hospital

Section 2 - Patient Information

**Patient First Name:

**Patient Last Name:

**Birth Date:

**Social Security Number:

**Mailing Address:

**City: **State: **Zip:

**Phone number where you may be reached if there are questions we need to ask you about your request:

**Date(s) of service: From To

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

Name of person, doctor, or place:

Address:

City: State: Zip:

Phone: Fax:

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

Name of person, doctor, or place:

Address:

City: State: Zip:

Phone: Fax:

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

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

Signature of patient or patient's guardian or representative:

Date of Signature: Apr 26 2024

Relationship to patient and basis of my authority to act:

Provider Directory

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