FORM

Authorization for Release of Information

First Name *

Last Name *

Date of Birth *

Authorization Period *

Current or Most Recent Provider *

Previous Provider Number *

Previous Provider Fax

Provider address *

City *

State/Province *

ZIP / Postal Code *

Country *

Scope *

Purpose of Request *

Please Specify *

I authorize my health information noted above to be sent to and discussed with: Asif Uddin, MD KC Psychiatrist, LLC 851 NW 45th st Ste 210 Phone (816) 708-0508 Fax: (816) 631-0118

Signature *