Patient Authorization to Release

In order to provide us with your authorization, please click here for the PDF version, or fill out and submit the form below. Thank you!


  • (Patient/Parent/Guardian Name)

    give permission to the following medical doctors/specialists to release the requested protected health information to Advanced Specialty Anesthesia, LLC

    In Regards To:
  • / /
  • Primary Medical Doctor: *

    Facility: *

    Address:

    - -

    - -
    Other Medical Doctor/Specialist:

    Facility:

    Address:

    - -

    - -
    Other Medical Doctor/Specialist:

    Facility:

    Address:

    - -

    - -



    / /

    - -

    - -

    - -

Note: Please complete your request by following the steps presented to you after submitting this form.

1201 Wakarusa Drive Suite A-3 | Lawrence, KS 66049 |
Office: (785) 856-6170 | Fax: (785) 422-5477

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