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. The authorization is good for one year, unless it is revoked. The Authorization to Exchange Medical Information is for verbal exchange only, all requests for copies of electronic and paper medical record must be requested through the appropriate standard authorization
Requesting Copies of Medical Records
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 (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 (pdf)