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Kansas City Psychiatric Group, P.A. 4500 College Blvd., Suite 304 Overland Park, KS 66211-1760 913-338-0400 913-338-0428 Fax AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION Client Name:
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How to Fill Out KCPSYCH:
01
Start by gathering all the necessary information such as personal details, including name, date of birth, contact information, and any relevant identification numbers.
02
Carefully read through each section of the KCPSYCH form to understand the information required and any instructions provided.
03
Begin by filling out the basic demographic information, ensuring accuracy and clarity in providing your personal details.
04
Move on to the section that requires details about your medical history. Provide any relevant information about previous illnesses, treatments, medications, or allergies that may be necessary for evaluation purposes.
05
Proceed to fill out the section related to your mental health history. Include details about any previous diagnoses, therapy or counseling received, or any current mental health conditions.
06
If applicable, provide information about any current medications you are taking or any ongoing treatments or therapies related to your mental health.
07
In case there is a specific section for documenting symptoms or concerns, describe any challenges or issues you are currently experiencing that may require assessment or intervention.
08
If there are any additional sections or spaces for comments, utilize them to further elaborate on any particular details you feel are important for the evaluator to know.
09
Review the form once you have filled it out to ensure accuracy and completeness of the information provided.
10
Finally, sign and date the form as required, certifying that the information given is correct to the best of your knowledge.
Who Needs KCPSYCH:
01
Individuals seeking psychological or psychiatric evaluation and assessment may need to complete a KCPSYCH form.
02
Patients who wish to receive mental health services, treatment, or therapy often require a completed KCPSYCH form to provide necessary background information to the practitioners.
03
Medical professionals, psychologists, psychiatrists, or therapists may also require patients to fill out the KCPSYCH form to aid their diagnosis and treatment planning process.
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