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.
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.
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