Kaiser Authorization Medical Records Release Form

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PATIENT
NICKNAME / MAIDEN NAME / OTHER
SOCIAL SECURITY
HEALTH RECORD NO.
Kaiser Foundation Health Plan of the Northwest • Kaiser Foundation Hospitals
DATE OF BIRTH: (MO/DAY/YR)
PHONE NUMBER
Kaiser Permanente Health Alternatives
(
)
ADDRESS
STREET OR BX NUMBER
Authorization for Kaiser Permanente to
Use/Disclose Protected Health Information
CITY
STATE
ZIP + 4
I authorize Kaiser Permanente to release the following information for the purpose of: _________________________
____________________________________________________________________________________________________
Description of information to be used/disclosed (Be as specific as possible):
❏ All records
X-ray films (describe):___________________________________________________________________________
Other (describe): ______________________________________________________________________________
Please send my protected health information to:
NAME OF PERSON TO RECEIVE INFORMATION
TITLE (PHYSICIAN, ATTORNEY, ETC.)
PHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP CODE
If the information to be used/disclosed contains any of the types of records or information listed below, additional laws relating to
the use and disclosure of the information may apply. I understand and agree that this information will be used or disclosed if I
place my initials in the applicable space next to the type of information:
___________Drug/Alcohol diagnosis, treatment or referral information
___________Mental Health information – including provider notes
___________HIV/AIDS information
___________Genetic testing information
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer be
protected under federal law. However, I also understand that federal or state law may restrict redisclosure of drug/alcohol diag-
nosis, treatment or referral information, mental health information and genetic testing information.
You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health
care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care
service is if the health care services are solely for the purpose of providing health information to someone else and the authoriza-
tion is necessary to make that disclosure.
You may revoke this authorization in writing at any time. For Drug and Alcohol records, you may revoke this authorization orally
or in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed
for the purposes described in this written authorization. Any use or disclosure already made with your permission cannot be
undone. To revoke this authorization, please send a written statement to Kaiser Permanente, Release of Information Department
at 10220 SE Sunnyside Rd., Clackamas, Oregon 97015 and state that you are revoking this authorization. To revoke this authoriza-
tion orally, please call Release of Information at 503-571-5051 and state that you are orally revoking this authorization.
I have read this authorization and understand it. Unless revoked, this authorization expires in 24 months or shall
remain in effect for a period of time reasonably needed to effect the purpose for which it was given.
In Washington, this authorization may be limited by law to 90 days in certain situations.
X
X
_______________________________________________________
_____________________________________
SIGNATURE OF INDIVIDUAL OR PERSONAL REPRESENTATIVE
DATE
X
❏ Identity/Authority verified
_______________________________________________________
DESCRIPTION OF PERSONAL REPRESENTATIVE’S AUTHORITY
ASSIGNMENT OF BENEFITS:
FOR USE BY INSURANCE CLAIMS DEPARTMENT ONLY
My signature below authorizes payment by my insurer to the physician/hospital on benefits due to me but not to
exceed the balance of my account.
X
X
___________________________________________
__________________________________________
SIGNATURE OF INDIVIDUAL OR PERSONAL REPRESENTATIVE
DATE
White: OPMR - Scan
Yellow - Patient
0004-1756 3/26/07 ROI/PC

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