KS KDHE Authorization for Release of Immunization Information 2017 free printable template
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AUTHORIZATION FOR RELEASE OF IMMUNIZATION INFORMATION
Patient Name:/Date of Birth:Note: If the patient is
over the age of 18
years, the person
requesting the
information must be
the patient or personal
representative
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How to fill out KS KDHE Authorization for Release of Immunization Information
How to fill out KS KDHE Authorization for Release of Immunization Information
01
Obtain the KS KDHE Authorization for Release of Immunization Information form from the Kansas Department of Health and Environment website.
02
Fill out the personal information section with your full name, date of birth, and contact information.
03
Indicate the specific immunization records you wish to have released.
04
Provide the name and contact information of the individual or organization that will receive the immunization information.
05
Date and sign the form at the bottom to authorize the release.
06
Submit the completed form to the appropriate office as instructed on the form.
Who needs KS KDHE Authorization for Release of Immunization Information?
01
Individuals who need access to their own immunization records for educational, employment, or health care purposes.
02
Parents or legal guardians wanting to obtain immunization records for their children.
03
Employers or schools requiring proof of immunizations from prospective employees or students.
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What is KS KDHE Authorization for Release of Immunization Information?
The KS KDHE Authorization for Release of Immunization Information is a form that allows individuals to consent to the sharing of their immunization records with designated parties, such as healthcare providers, schools, or other organizations.
Who is required to file KS KDHE Authorization for Release of Immunization Information?
Individuals who wish to have their immunization information shared, or guardians acting on behalf of minors, are required to file the KS KDHE Authorization for Release of Immunization Information.
How to fill out KS KDHE Authorization for Release of Immunization Information?
To fill out the KS KDHE Authorization for Release of Immunization Information, individuals must provide personal information such as name, date of birth, and address, as well as specify the parties to whom the information will be released and the purpose of the release.
What is the purpose of KS KDHE Authorization for Release of Immunization Information?
The purpose of the KS KDHE Authorization for Release of Immunization Information is to enable the authorized sharing of immunization records to support healthcare, school requirements, and public health initiatives.
What information must be reported on KS KDHE Authorization for Release of Immunization Information?
The information that must be reported includes the individual's identifying information, information about the parties receiving the records, the purpose for the release, and any specific details regarding the immunization records being requested.
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