Request for Access to Protected Health Information

To Request Your or Your Child’s Records:

Patients and legal guardians, please complete the Request for Access to Protected Health Information by Individual Patients form to request a copy of your medical records sent to you or another legal guardian or personal representative.

Note: Parents and legal guardians, please use this form for your children.

Click Here to Request for Access to Patient's Protected Health Information

 

To Request An Individual Patient’s Records for a Third Party

Patients and Third Parties, please complete the Authorization for Release of Information form to request a copy of an individual’s medical records to be released to a third party individual or institution. Note: The individual patient whose records are being requested must sign this authorization.

Request for Records for 3rd Party

 

Completed Signature Psychiatric Hospital forms may be returned in person, fax, by mail or email to:

Signature Psychiatric Hospital
2900 Clay Edwards Drive

North Kansas City, MO 64116

sphhim@sphkc.com

Fax: 816-346-7034
Phone: 816-691-5164