Kaiser Authorization Medical Records Release Form (Page 2 of 2) in pdf

Instructions

How to fill out

“Authorization for Kaiser Permanente to Use/Disclose Protected Health Information” form

①

Complete each box as indicated with the following information:

• Patient’s Name (Print clearly)

• Other names the patient has used. If none, leave this box blank

• Social Security Number (Not required)

• Health Record Number

• Date of Birth

• Telephone Number where you can be reached during the day

• Home Street Address

• Home City, State and Zip Code

②

State the purpose for the release of information. Examples: Insurance application, Insurance Claim, Legal,

Benefits, School, Patient Care, etc. (For my own purposes may be used only if you are releasing records to

yourself)

③

Check the box(es) that apply to your request:

• Checking All Records will allow the release of any records needed to respond to your request unless

there is sensitive information (see ⑤). You may need to also INITIAL for sensitive information.

• By checking Other you will need to describe exactly what you want released. Examples: All records

regarding my back injury, or All information needed to complete the attached form, etc.

• Check X-ray films only if you want the actual films to be released.

④

Write the name or company of who is to receive the information. Include:

• Name or Company

• Title of who is to receive the information. Examples: Attorney, Physician, etc.

• Telephone of the person or company who will receive the information

• Street address of who will receive the information

• City, State and Zip Code of who will receive the information

⑤

INITIAL for any sensitive information protected by law you want to be released.

⑥

Sign the authorization. If you are not the patient, describe your relationship and legal authority to sign. You

will be required to provide the legal paperwork.

⑦

Date the authorization.

Sometimes there is a fee to disclose records. If you will be responsible to pay for the records please indicate by

writing “BILL ME” on the authorization. You may call 800-813-2000, extension 31-5051, for questions

regarding costs. Please indicate if you are a Washington or Oregon member.

If you have any other questions regarding the completion of this authorization, please call 800-813-2000,

extension 31-5051, between 8:00 a.m. and 4:30 p.m., Monday through Friday.

RETURN TO:

Release of Information Department

Kaiser Permanente

10220 S.E. Sunnyside Road

Clackamas, OR 97015-9764

Kaiser Authorization Medical Records Release Form Page 2

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