This Authorization to Release Confidential Information will ensure that only the information you specify is released on your behalf. This authorization can be given to a physician, attorney, hospital, clinic or school to release confidential information on your behalf. The types of confidential information to be released can vary from financial, educational and legal to your social interactions, both online and in person. This Authorization to Release Confidential Information is beneficial because it protects not only your privacy but contains an expiration date and can be revoked at any time.

These important provisions are included in this Kansas Authorization to Release Confidential Information:

• Authorization Information: Indicates the name and address of the individual authorizing release of the information and the individual or entity who is authorized to release the confidential information;
• Types of Confidential Information: Sets forth a checklist covering many types of confidential information;
• Purpose of Use: Outlines the purposes for which the confidential information may be used;
• Revocation and Expiration Dates: The authorization expires on a specified date and may be revoked at any time.

Protect Yourself and your Rights by using our professionally prepared up-to-date forms.

This attorney prepared packet includes:

1. General Information
2. Instructions and Checklist
3. Authorization to Release Confidential Information for use in Kansas

State Law Compliance: This form complies with the laws of Kansas