← Paul Test
doc12838 consent_to_release.pdf
⬇ Export JSONBadge numbers are the reading order (depth-first). Nested children have dashed borders; grandchildren dotted. Hover a box for its type, text and attributes.
Page 1
54 item(s)
JSON
figure (1)
footer (2)
form_field (4)
header (1)
heading (2)
list (1)
list_item (6)
table (2)
table_cell (23)
text (10)
title (2)
1 · HEADER
2 · FIGURE
3 · TITLE
4 · TEXT
5 · TITLE
6 · HEADING
7 · TABLE
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30 · LIST
31
32
33
34
35
36
37 · TABLE
38
39
40 · TEXT
41 · TEXT
42 · HEADING
43 · TEXT
44
45 · TEXT
46 · TEXT
47 · TEXT
48 · TEXT
49 · TEXT
50
51 · TEXT
52 · FORM_FIELD
53 · FOOTER
54 · FOOTER
Table integrity:
1 of 22 cells don't match the text layer at their coordinates.
r6c3 (0%): “City State Zip”
Page 1 JSON
{
"document_id": 12838,
"page": 1,
"width_pt": 612,
"height_pt": 792,
"rotation": 0,
"pipeline_version": "paddleocr-vl-1.6+paul-48",
"engine": "paddleocr_vl",
"source_run_id": 12949,
"item_count": 54,
"counts_by_type": {
"figure": 1,
"footer": 2,
"form_field": 4,
"header": 1,
"heading": 2,
"list": 1,
"list_item": 6,
"table": 2,
"table_cell": 23,
"text": 10,
"title": 2
},
"build_ms": 9,
"items": [
{
"id": "p1.1",
"order": 1,
"type": "header",
"bbox": {
"l": 70.08,
"t": 705.6,
"r": 146.16,
"b": 671.52
},
"text": "Student Health\nT: (502) 597-6271\nF: (502) 597-6565",
"attrs": {
"block_label": "header"
},
"level": 2
},
{
"id": "p1.2",
"order": 2,
"type": "figure",
"bbox": {
"l": 253.68,
"t": 752.16,
"r": 360.24,
"b": 681.6
},
"text": "",
"attrs": {
"role": "page_header",
"block_label": "header_image"
}
},
{
"id": "p1.3",
"order": 3,
"type": "title",
"bbox": {
"l": 250.56,
"t": 660,
"r": 349.92,
"b": 625.68
},
"text": "Student Health Services\n400 East Main Street\nFrankfort, KY 40601",
"attrs": {
"block_label": "doc_title"
},
"level": 2
},
{
"id": "p1.4",
"order": 4,
"type": "text",
"bbox": {
"l": 429.84,
"t": 705.6,
"r": 508.08,
"b": 660.72
},
"text": "Counseling\nT: (502) 597-6969\nT: (502) 597-6970\nF: (502) 597-6565"
},
{
"id": "p1.5",
"order": 5,
"type": "title",
"bbox": {
"l": 156.72,
"t": 614.16,
"r": 454.8,
"b": 601.2
},
"text": "Consent to Release Confidential Health Care Information",
"attrs": {
"block_label": "doc_title"
},
"level": 2
},
{
"id": "p1.6",
"order": 6,
"type": "heading",
"bbox": {
"l": 71.52,
"t": 600.48,
"r": 110.88,
"b": 590.4
},
"text": "1. Patient",
"attrs": {
"block_label": "paragraph_title"
},
"level": 3
},
{
"id": "p1.7",
"order": 7,
"type": "table",
"bbox": {
"l": 70.8,
"t": 593.52,
"r": 577.2,
"b": 374.64
},
"text": "",
"attrs": {
"block_label": "table",
"n_rows": 8,
"n_cols": 4,
"integrity": {
"cells_checked": 22,
"cells_flagged": 1,
"flags": [
{
"row": 6,
"col": 3,
"coverage": 0,
"text": "City State Zip"
}
]
}
},
"children": [
{
"id": "p1.7.1",
"order": 8,
"type": "table_cell",
"bbox": {
"l": 77.775,
"t": 587.42,
"r": 159.29,
"b": 577.42
},
"text": "Name-Last, First, MI",
"attrs": {
"row": 0,
"col": 0,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true,
"column_header": true,
"header_source": "heuristic"
}
},
{
"id": "p1.7.2",
"order": 9,
"type": "table_cell",
"bbox": {
"l": 396.49,
"t": 587.42,
"r": 414.9,
"b": 577.42
},
"text": "DOB",
"attrs": {
"row": 0,
"col": 1,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true,
"column_header": true,
"header_source": "heuristic"
}
},
{
"id": "p1.7.3",
"order": 10,
"type": "table_cell",
"bbox": {
"l": 484.95,
"t": 587.42,
"r": 523.83,
"b": 577.42
},
"text": "KSU Class",
"attrs": {
"row": 0,
"col": 2,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true,
"column_header": true,
"header_source": "heuristic"
}
},
{
"id": "p1.7.4",
"order": 11,
"type": "table_cell",
"bbox": {
"l": 323.13,
"t": 439.46,
"r": 381.72,
"b": 430.46
},
"text": "Street Address",
"attrs": {
"row": 1,
"col": 0,
"rowspan": 1,
"colspan": 4,
"bbox_refit": true
}
},
{
"id": "p1.7.5",
"order": 12,
"type": "table_cell",
"bbox": {
"l": 77.775,
"t": 558.17,
"r": 93.055,
"b": 548.17
},
"text": "City",
"attrs": {
"row": 2,
"col": 0,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.6",
"order": 13,
"type": "table_cell",
"bbox": {
"l": 289.88,
"t": 558.17,
"r": 310.85,
"b": 548.17
},
"text": "State",
"attrs": {
"row": 2,
"col": 1,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.7",
"order": 14,
"type": "table_cell",
"bbox": {
"l": 358.38,
"t": 558.17,
"r": 370.79,
"b": 548.17
},
"text": "ZIP",
"attrs": {
"row": 2,
"col": 2,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.8",
"order": 15,
"type": "table_cell",
"bbox": {
"l": 424.84,
"t": 558.17,
"r": 450.83,
"b": 548.17
},
"text": "Phone",
"attrs": {
"row": 2,
"col": 3,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.9",
"order": 16,
"type": "table_cell",
"bbox": {
"l": 72.025,
"t": 533.75,
"r": 244.79,
"b": 478.73
},
"text": "2. Release Information FROM:\n__ KSU Student Health Services\n__ KSU Counseling\nTreatment Provider (if applicable)\n__ Other (complete box below):",
"attrs": {
"row": 3,
"col": 0,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true,
"merged_continuation": true
}
},
{
"id": "p1.7.10",
"order": 17,
"type": "table_cell",
"bbox": {
"l": 324.13,
"t": 533.75,
"r": 496.89,
"b": 478.73
},
"text": "3. Release Information TO:\n__ KSU Student Health Services\n__ KSU Counseling\nTreatment Provider (if applicable)\n__ Other (complete box below):",
"attrs": {
"row": 3,
"col": 1,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true,
"merged_continuation": true
}
},
{
"id": "p1.7.11",
"order": 18,
"type": "table_cell",
"bbox": {
"l": 77.525,
"t": 465.23,
"r": 250.715,
"b": 456.23
},
"text": "Name (i.e., Health Facility, Physician, etc.)",
"attrs": {
"row": 4,
"col": 0,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true
}
},
{
"id": "p1.7.12",
"order": 19,
"type": "table_cell",
"bbox": {
"l": 323.13,
"t": 465.23,
"r": 496.43,
"b": 456.23
},
"text": "Name (i.e., Health Facility, Physician, etc.)",
"attrs": {
"row": 4,
"col": 1,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true
}
},
{
"id": "p1.7.13",
"order": 20,
"type": "table_cell",
"bbox": {
"l": 77.525,
"t": 439.46,
"r": 136.115,
"b": 430.46
},
"text": "Street Address",
"attrs": {
"row": 5,
"col": 0,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true
}
},
{
"id": "p1.7.14",
"order": 21,
"type": "table_cell",
"bbox": {
"l": 77.775,
"t": 572.92,
"r": 137.155,
"b": 562.92
},
"text": "Street Address",
"attrs": {
"row": 5,
"col": 1,
"rowspan": 1,
"colspan": 2,
"bbox_refit": true
}
},
{
"id": "p1.7.15",
"order": 22,
"type": "table_cell",
"bbox": {
"l": 77.525,
"t": 415.96,
"r": 94.765,
"b": 406.96
},
"text": "City",
"attrs": {
"row": 6,
"col": 0,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.16",
"order": 23,
"type": "table_cell",
"bbox": {
"l": 207.33,
"t": 415.96,
"r": 227.29,
"b": 406.96
},
"text": "State",
"attrs": {
"row": 6,
"col": 1,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.17",
"order": 24,
"type": "table_cell",
"bbox": {
"l": 272.31,
"t": 415.96,
"r": 286.09,
"b": 406.96
},
"text": "Zip",
"attrs": {
"row": 6,
"col": 2,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.18",
"order": 25,
"type": "table_cell",
"bbox": {
"l": 450.6,
"t": 411.12,
"r": 577.2,
"b": 392.88
},
"text": "City State Zip",
"attrs": {
"row": 6,
"col": 3,
"rowspan": 1,
"colspan": 1
}
},
{
"id": "p1.7.19",
"order": 26,
"type": "table_cell",
"bbox": {
"l": 77.525,
"t": 394.96,
"r": 119.935,
"b": 385.96
},
"text": "Telephone #",
"attrs": {
"row": 7,
"col": 0,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.20",
"order": 27,
"type": "table_cell",
"bbox": {
"l": 199.58,
"t": 394.96,
"r": 214.57,
"b": 385.96
},
"text": "Fax #",
"attrs": {
"row": 7,
"col": 1,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.21",
"order": 28,
"type": "table_cell",
"bbox": {
"l": 323.13,
"t": 394.96,
"r": 365.54,
"b": 385.96
},
"text": "Telephone #",
"attrs": {
"row": 7,
"col": 2,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
},
{
"id": "p1.7.22",
"order": 29,
"type": "table_cell",
"bbox": {
"l": 451.93,
"t": 394.96,
"r": 466.92,
"b": 385.96
},
"text": "Fax #",
"attrs": {
"row": 7,
"col": 3,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true
}
}
]
},
{
"id": "p1.8",
"order": 30,
"type": "list",
"bbox": {
"l": 69.84,
"t": 361.36,
"r": 297.84,
"b": 351.36
},
"text": "",
"attrs": {
"item_count": 6
},
"children": [
{
"id": "p1.8.1",
"order": 31,
"type": "list_item",
"bbox": {
"l": 72.025,
"t": 361.18,
"r": 296.34,
"b": 352.18
},
"text": "Information to be Released (Check All That Apply)",
"marker": "4."
},
{
"id": "p1.8.2",
"order": 32,
"type": "list_item",
"bbox": {
"l": 69.84,
"t": 361.36,
"r": 297.84,
"b": 359.36
},
"text": "Attendance/Participation in Counseling",
"marker": "—",
"attrs": {
"bbox_estimated": true
}
},
{
"id": "p1.8.3",
"order": 33,
"type": "list_item",
"bbox": {
"l": 69.84,
"t": 359.36,
"r": 297.84,
"b": 357.36
},
"text": "Psychotherapy notes",
"marker": "—",
"attrs": {
"bbox_estimated": true
}
},
{
"id": "p1.8.4",
"order": 34,
"type": "list_item",
"bbox": {
"l": 69.84,
"t": 357.36,
"r": 297.84,
"b": 355.36
},
"text": "Result of evaluations",
"marker": "—",
"attrs": {
"bbox_estimated": true
}
},
{
"id": "p1.8.5",
"order": 35,
"type": "list_item",
"bbox": {
"l": 69.84,
"t": 355.36,
"r": 297.84,
"b": 353.36
},
"text": "Clinical summary letter or email",
"marker": "—",
"attrs": {
"bbox_estimated": true
}
},
{
"id": "p1.8.6",
"order": 36,
"type": "list_item",
"bbox": {
"l": 69.84,
"t": 353.36,
"r": 297.84,
"b": 351.36
},
"text": "Verbal clinical summary",
"marker": "—",
"attrs": {
"bbox_estimated": true
}
}
]
},
{
"id": "p1.9",
"order": 37,
"type": "table",
"bbox": {
"l": 72.24,
"t": 350.88,
"r": 493.44,
"b": 294.93
},
"text": "",
"attrs": {
"block_label": "table",
"n_rows": 1,
"n_cols": 1,
"integrity": {
"cells_checked": 1,
"cells_flagged": 0
}
},
"children": [
{
"id": "p1.9.1",
"order": 38,
"type": "table_cell",
"bbox": {
"l": 84.525,
"t": 349.68,
"r": 209.085,
"b": 294.93
},
"text": "_Complete Copy of All Records\n_Immunizations\n_Lab Results\n_Progress Notes: all\nOr specified dates",
"attrs": {
"row": 0,
"col": 0,
"rowspan": 1,
"colspan": 1,
"bbox_refit": true,
"merged_continuation": true
},
"children": [
{
"id": "p1.9.1.1",
"order": 39,
"type": "form_field",
"bbox": {
"l": 108.05,
"t": 307.63,
"r": 272.97,
"b": 294.29
},
"text": "",
"attrs": {
"field_kind": "text",
"label": "Or specified dates",
"source": "blank_line",
"row": 0,
"col": 0,
"rowspan": 1,
"colspan": 1,
"label_source": "parent_text",
"label_ref": "p1.9.1"
}
}
]
}
]
},
{
"id": "p1.10",
"order": 40,
"type": "text",
"bbox": {
"l": 322.8,
"t": 339.36,
"r": 421.68,
"b": 328.56
},
"text": "Psychotherapy notes"
},
{
"id": "p1.11",
"order": 41,
"type": "text",
"bbox": {
"l": 323.04,
"t": 328.32,
"r": 423.6,
"b": 317.28
},
"text": "Result of evaluations"
},
{
"id": "p1.12",
"order": 42,
"type": "heading",
"bbox": {
"l": 71.04,
"t": 293.28,
"r": 149.52,
"b": 282.24
},
"text": "___ Other (specify):",
"level": 3
},
{
"id": "p1.13",
"order": 43,
"type": "text",
"bbox": {
"l": 70.8,
"t": 288.96,
"r": 462.48,
"b": 272.88
},
"text": "I am a",
"children": [
{
"id": "p1.13.1",
"order": 44,
"type": "form_field",
"bbox": {
"l": 72.025,
"t": 284.61,
"r": 462.17,
"b": 271.27
},
"text": "",
"attrs": {
"field_kind": "text",
"source": "blank_line",
"label": "I am a",
"label_source": "parent_text",
"label_ref": "p1.13"
}
}
]
},
{
"id": "p1.14",
"order": 45,
"type": "text",
"bbox": {
"l": 70.56,
"t": 270.72,
"r": 536.88,
"b": 249.6
},
"text": "Check here if ONLY Records May Be Released (i.e. conversations, including those intended for clarification or follow-up, are not authorized)"
},
{
"id": "p1.15",
"order": 46,
"type": "text",
"bbox": {
"l": 71.04,
"t": 239.04,
"r": 276.96,
"b": 227.76
},
"text": "5. Purpose for Disclosure (check All That Apply)"
},
{
"id": "p1.16",
"order": 47,
"type": "text",
"bbox": {
"l": 335.28,
"t": 227.76,
"r": 372.72,
"b": 216.24
},
"text": "Personal"
},
{
"id": "p1.17",
"order": 48,
"type": "text",
"bbox": {
"l": 74.64,
"t": 227.52,
"r": 538.32,
"b": 204
},
"text": "_ Facilitate coordination of health care\n_ Academic Adjustment or Accommodations"
},
{
"id": "p1.18",
"order": 49,
"type": "text",
"bbox": {
"l": 73.2,
"t": 216.72,
"r": 540,
"b": 203.04
},
"text": "— Other (specify): _____",
"children": [
{
"id": "p1.18.1",
"order": 50,
"type": "form_field",
"bbox": {
"l": 324.13,
"t": 217.86,
"r": 537.7,
"b": 204.52
},
"text": "",
"attrs": {
"field_kind": "text",
"label": "— Other (specify): _____",
"source": "blank_line",
"label_source": "parent_text",
"label_ref": "p1.18"
}
}
]
},
{
"id": "p1.19",
"order": 51,
"type": "text",
"bbox": {
"l": 69.6,
"t": 193.92,
"r": 540.24,
"b": 110.4
},
"text": "I understand that I am giving my permission to the above named treatment provider or other named third party for disclosure of confidential health care information, including both records and discussions pertaining to those records, unless otherwise noted in Section 4 above. This consent is not a condition for treatment at the Kentucky State University Student Health Services or Counseling. I also understand that I have a right to revoke this consent, but that my revocation is not effective until delivered in writing to the person who is in possession of my records. A copy of this consent and a notation concerning the persons or third parties to who disclosure was made shall be included with my original records. The person who receives the records to which this consent pertains may be subject to re-disclosure by the recipient and no longer protected. I have the right to refuse to sign this authorization."
},
{
"id": "p1.20",
"order": 52,
"type": "form_field",
"bbox": {
"l": 72.025,
"t": 102.752,
"r": 506.4,
"b": 90.746
},
"text": "",
"attrs": {
"field_kind": "text",
"source": "blank_line"
}
},
{
"id": "p1.21",
"order": 53,
"type": "footer",
"bbox": {
"l": 72.24,
"t": 90.72,
"r": 268.8,
"b": 80.16
},
"text": "Signature of Patient (or parent/guardian if under 18)",
"attrs": {
"block_label": "footer"
}
},
{
"id": "p1.22",
"order": 54,
"type": "footer",
"bbox": {
"l": 358.08,
"t": 90.48,
"r": 538.56,
"b": 79.92
},
"text": "Date (Document expires one year from this date)",
"attrs": {
"block_label": "footer"
}
}
],
"excluded_furniture": {
"first": [],
"last": []
}
}