Please print and complete an attached form (below) and mail it to:
Wesley Medical Center
Health Information Management
Release of Information
550 North Hillside
Wichita, Kansas 67214
The Health Insurance Portability and Accountability Act (HIPAA) requires that all portions of the attached form be completed. The form is to be signed and dated by the patient or legal representative. Please call 316 962-2513 if you have questions.
- Instruction for Authorization for Use and Disclosure Forms
- Authorization for Use and Disclosure - English (MR764)
- Autorización para el Uso y Divulgación - Spanish (MR764B)
These forms require Adobe Reader. If you do not have Adobe Reader, you may download it free here:
(this link opens a new browser window).