Which itemized statement are you requesting? (You must choose an option) KMSF University of Kentucky / Good Sam Both Requestor Information Name: Relation to Patient: SelfSpouseParentChildGrandparentGrandchildNiece/Nephew Please note, if patient differs from requestor, a signed authorization form is required to release patient records. Patient Information (* All fields are required *) Name: Patient Name Required Address: Patient Address Required City: Patient City Required State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAmerican SamoaGuamNorthern Mariana IslandsPuerto RicoUnited States Minor Outlying IslandsVirgin IslandsArmed Forces AmericasArmed Forces PacificArmed Forces OthersOther Patient State Required Zip: Patient Zip Required Phone: Date of Birth: Last 4 Digits of SSN: Miscellaneous Information Dates of Service: Through: Is this for a cancer policy? Submit request Processing × Goodbye Please allow up to 30 business days for your request to be processed. × Required fields missing! All fields are required and must be completed before the request may be submitted.
