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Available Forms

Request of Prior Records

Manish Dixit, M.D., F.A.A.P.1902 S. US HWY 59, Suite 5Parsons, KS. 67357(620)421-0002 phone(888)820-2325 fax

Please fill out only the lines with the * next to them.

To disclose protected health information to:

Dr. Manish Dixit, M.D. 1902 US Hwy 59, Suite5 Parsons, KS 67357

I understand that requested information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services and treatment of alcohol and drug abuse. This information will be released unless objection is made by checking the statement below:

If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment or payment or your eligibility for benefits. You may inspect or copy the protected health information to be used or disclosed under this authorization. For protected health information created as part of a clinical trial, your right to access is suspended until the clinical trial is completed. Finally, you may revoke this authorization in writing at any time by sending written notification to M. Dixit LLC. Your notice will not apply to actions taken by the requesting person/entity prior to the date they receive your written request to revoke authorization.

Verification of Information Released

* Required field