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GEENENS PSYCHIATRY, PA
4901 W. 136TH ST. 
LEAWOOD, KANSAS 66224
Tel: 913-488-2012 Fax: 913-276-7274

AUTHORIZATION FOR RELEASE OF INFORMATION

Please fill out and submit the Release of Information Form (ROI). 

Once completed, our Patient Care Administrator will contact you within 24 hours.

PATIENT INFORMATION

RELEASE OF INFORMATION TO FACILITY

RELEASE OF INFORMATION TO OTHERS

 ACKNOWLEDGEMENT 

I authorize Geenens Psychiatry to release confidential information about me, by releasing a copy of my medical records, or by a summary/narrative of my psychiatric information to the facilities/physicians/individuals listed above. 

I have a right to revoke this authorization at any time. I understand that if I revoke this authorization, I must do so in writing and present it to Geenens Psychiatry Administration via email, regular mail, fax or in person. Revocation will not apply to information that has already been released in response to this authorization. I certify that a photocopy of this authorization is as valid as the original. 

I acknowledge and certify that I am indeed the individual signing this authorization. Falsifying a signature is considered fraud and is punishable by Federal Law. 

Thank you for submitting this form! We will contact you within 24 hours.

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