Liberty Slots Authorization Form
Funding a real-money account at Liberty Slots Casino makes it possible for gamblers both within and outside of the United States to make cash wagers on the games that they play. Gamers who want easy, secure access to high-quality online casino banking will be thrilled to discover that depositing and withdrawing cash from a Liberty Slots account. Complete the appropriate WellCare notification or authorization form for Medicare. You can find these forms by selecting “Providers” from the navigation bar on this page, then selecting “Forms” from the “Medicare” sub-menu. Fax the completed form(s) and any supporting documentation to the fax number listed on the form. Liberty Slots Casino provides its members with numerous user-friendly banking options. Of course, members are invited to use Visa and MasterCard. The caveat to this banking option is that you must have a credit card authorization form on file. Once approved by Liberty Slots Casino, the deposits you make are free of charge.
How to request copies of your medical record
Patients and guardians can request copies of medical records following a visit at a Liberty Hospital facility. We offer three ways for you to access your medical records:
- Free online access through the Patient Portal. The best way to access your health records is via the Patient Portal, where you can see much of your hospital information anytime it's convenient for you. If you aren't signed up, ask your care team to help you sign up the next time you visit.
- Electronic delivery If you are a patient or guardian, you can request to have your medical records sent to you in an electronic format by completing an online authorization form. Click here to access the online authorization form.
- Hard Copies* If you are a patient or guardian and need hard copies of your medical records for yourself or a third party: Download, print and complete the Authorization for Release Formand then mail, fax or deliver in person to Liberty Hospital address or fax number below.
Health Information Management Department/Release of Information
Liberty Hospital
2525 Glenn Hendren Drive, Liberty, MO 64068
Phone: 816.792.7067
Fax: 816.792.7114
Email: recordrequest@libertyhospital.org
*Please note, the recordrequest@libertyhospital.org is not a secure email address. If you have concerns, please email us your name and we will send you a secure response for all future correspondence.
If you have questions, please call Liberty Hospital Release of Information, Monday-Friday, 8:00 a.m. – 4:30 p.m. at 816.792.7067. Records will be returned to you within 24-72 hours. Please allow additional time if records are being mailed.
NO walk-in requests are accepted at this time.
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Authorization Form Template
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Liberty Slots Authorization Form 2020
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