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59-2946 SUBSTANCE ABUSE STATUTE 42 CFR-PART 2 AND/OR HIV/AIDS OR OTHER COMMUNICABLE DISEASE K. S.A. THE AUTHORIZING INDIVIDUAL UNDERSTANDS THAT SAID INFORMATION DISCLOSED MAY CONTAIN PSYCHIATRIC K. S.A. PATIENT/LEGAL REPRESENTATIVE INITIAL PRINTED NAME OF PERSON AUTHORIZING THE RELEASE PATIENT OR AUTHORIZED REPRESENTATIVE PATIENT SIGNATURE DATE PARENT/GUARDIAN/LEGAL REPRESENTATIVE SIGNATURE ADDRESS/PHONE RELATIONSHIP WITNESS SIGNATURE PLEASE READ THE ENTIRE FORM BOTH FRONT AND BACK PAGES...

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