Lafene Health Center
Kansas State University
1105 Sunset Avenue
Manhattan, KS 66502-3761
785-532-6544
lafene@k-state.edu

Questions?
Call 785.532.6544

Statement Address Authorization

Print, complete and return to:

Lafene Health Center
1105 Sunset Avenue
Kansas State University,
Manhattan, KS 66502-3575

Date: _______________________________________

In signing this form I am authorizing only Lafene Health Center statements to be sent to my permanent address.

Permanent Address:

______________________________________________________________

_______________________________________________________________

I also understand billing statements may contain confidential and personal detailed medical information about all medical services performed at Lafene Health Center.

Print Name: ______________________________________________________

Signature: _______________________________________________________

Social Security #: __________________________________________________

Manhattan Address:

______________________________________________________________
_______________________________________________________________

09/10/01; Revised 03/07/02; 11/02; 09/03

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