Request for Assistance

Name:________________________________________________________________________

Address:______________________________________________________________________

City:_________________________ State:__________________ Zip Code:________________

Telephone Number (Home):____________ (Work):______________ (Cellular):______________

Date of Birth: ______________________ Social Security Number: __________________

TYPE OF ASSISTANCE REQUESTED:

____ Amtryke _____ Cash (Maximum $500.00 to be paid directly to provider)

What Assistance is Requested:____________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Statement of Nature of Illness/Disability:_____________________________________________

Name and Address of Primary Physician:____________________________________________

__________________________________________________________________________________________________________________________________________________________

Release of Medical Information

1. PATIENT INFORMATION.

Name: ___________________________________

Address: _________________________

_________________________, Kansas ________

SSN: __________________

Date of Birth: __________________

2. AUTHORIZATION FOR RELEASE. I hereby authorize _____________________________(medical provider) of _________________________(organization), _________________________(city), ____________(state), to release, disclose, and deliver the medical information described below to:

Authorized Recipient:

Red Baron Chapter of National Ambucs, Inc.

P.O. Box 2413

Salina, Kansas 67402-2413

3. SPECIFIC AUTHORIZATION. I specifically authorize the release of all medical information relating to the above-named patient including but not limited to the following categories protected by state or federal law: (1) Substance abuse (drug or alcohol) treatment (2) Mental health treatment and (3) HIV-AIDS-related information, if such information is contained in the records. This request includes any reports, correspondence, test results, and any other information contained in the records, whether generated by the authorized provider or another entity.

I do not give permission for any other use or redisclosure of this information.

Dated: ______________ ______________________________________(patient)

4. VALIDITY. I understand that this authorization will automatically expire one year from the date of my signature, and that I may revoke this authorization by sending a written notice to the person or entity authorized to make the disclosure described above. I agree that any release which has been made prior to revocation and which was made in reliance upon this authorization shall not constitute a breach of my rights to confidentiality.

I authorize the release of information as indicated above.

Dated: ______________ ________________________________________(patient)