Records Request

Consent to Obtain Records
Name of Provider*
Fax*
Phone*
Address*
Street Address City, State ZIP / Postal Code
Request for Prenatal Records
My Name:*
New Birth Company Location:*
- Overland Park
- Kansas City, KS
I am requesting a copy of my prenatal records including:

Demographics | History & Physical | Lab | Ultrasound | Prenatal Flow Sheets | Encounters | Consults | Other Diagnostics
Please forward to:
New Birth Company, 9209 West 110th Street Building #36, Overland Park KS 66210
Phone: 913.735.4888
Fax: 1.888.927.5843
Please forward to:
New Birth Company, 721 North 31st Street #100, Kansas City KS 66102
Phone: 913.802.2325
Fax: 1.913.725.0573
Printed Name*
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Signature*
Date*
Date Format: MM slash DD slash YYYY
At this time, I understand that this authorization may be revoked in writing by me at any time, except to the extent that this action has been taken. I understand that any release which was made prior to my revocation in compliance with this authorization shall not constituent a breach of my rights to confidentiality. I also understand that if the requestor or receiver of my medical records is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed. This authorization will automatically expire one year from the date of signature.
Witness Signature*
Date*
Date Format: MM slash DD slash YYYY
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Consent to Obtain Records