AUTHORIZATION TO OBTAIN INFORMATION

Patient Name:_____________________________Date of Birth:__________________________

I hereby authorize the following entity to release my personal health and medical information to

Prairie Surgical Care, LLC, Carlo C. Jurani, MD LLC, Ralph Park MD, LLC

This information should be delivered, mailed, or faxed to the following:

Prairie Surgical Care, LLC

8901 W. 74th  Street

Suite 312

Shawnee Mission, KS 66204

Phone 913-432-4355            Fax 913-432-5994

This release will include the following: ____ Entire medical record

Other (specify) ____________________

The patient or the patient's representative must read and initial the following statements:

___I understand: (a) this authorization is voluntary; (b) I may inspect or receive a copy of the

information described on this form if I ask for it and that I may have a copy of this form after I sign it; (c) this authorization will expire in one year unless otherwise specified _________.

___I understand that I may cancel this authorization at any time by notifying the providing health care provider in writing.

___I understand that if the recipient of the information listed above is not a healthcare provider or healthcare plan covered by the federal privacy regulations, the released information may be redisclosed by such person or entity and will likely no longer be protected by the federal privacy regulations. The recipient may otherwise be prohibited under federal law from redisclosing substance abuse information, AIDS/HIV status or mental health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law.

________________________________________________________    ___________________

Signature of patient/guardian/representative                                             Date

If signed by other than patient, indicate relationship ___________________________________

Address and phone number _______________________________________________________

Printed name of representative ____________________________________________________