Health Information

To submit the completed forms you can use mail, fax, or bring them in during your next visit. Our contact information is listed to the right.

Authorizing Verbal Exchange of Information

Patients, parents, or a legal guardian must provide authorization before Children's Mercy can exchange information (by phone or in person) with another facility or individual. Verbal exchange can be authorized by completing the Authorization for Release of Medical Information by Children’s Mercy form below and filling out section #2. Requests for copies of medical information MUST have another method of disclosure (mail, fax, email) selected. 

Authorization for release of medical information by Children's Mercy (PDF)

Limiting Access to Health Information

Patients, parents, or legal guardians may request to limit the access, use, or disclosure of a patient's protected health information for treatment, payment, or health care operations by completing the form listed below:

Request for Restrictions to the Use and Disclosure of Protected Health Information (English/Spanish) (PDF)

Requesting Changes to Health Information

Patients, parents, or legal guardians may request an amendment (change or correction) to a patient's health information by completing the form below. Once the form is complete and sent to the Health Information Manager, authors of the content will be notified. Authors may select to accept or deny the requested changes. Patients, parents, or legal guardians will be notified by mail once a decision has been made.

Request for Amendment of Health Information in English or Spanish (PDF)

Requesting Medical Records

An authorization to release a copy of a patient's medical record must be completed with the patient's name and date of birth. The authorization must be signed by the patient's legal guardian or the patient (if the patient is 18 years or older). Authorizations must be dated within one year of receipt are good for up to one year until completed. Once a valid authorization is received, we will respond to your request within 30 days. 

Requesting Medical Records