AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

Please correct the errors described below.

Name: HEALTH CARE FOR CHILDREN

Address: 9051 NE 81st Terrace, Suite 100 City: Kansas City State: MO Zip: 64158

Phone Number: 816-792-1170 Fax: 816-792-0729

If left blank, this Authorization will expire (1) year from the date this Authorization is signed.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign the authorization. I need not sign this form to ensure treatment. I understand that I may inspect the information to be used or disclosed. If I have questions about disclosure of my health information, I can contact the privacy officer.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your information will be encrypted.

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