Patient Name: _________________________________________
Medical Record number: ________________ Birth Date: _________
(*Kaiser Permanente entities are
listed on reverse side of this form)
Address: ______________________________________________
AUTHORIZATION FOR USE
City: _______________________________ State: _____________
OR DISCLOSURE OF PATIENT
Zip Code: ____________ Phone #: __________________________
(
)
HEALTH INFORMATION
Email: ________________________________________________
Note: Fees may apply to certain requests
Kaiser Permanente may release this information to: q Check if same as above
Recipient Name: _______________________________________________________________________
Address: ________________________________ City: ______________ State:______ Zip Code:________
Phone # ________________________________ Email: ________________________________________
(
)
This disclosure can be used for the following purpose(s): q Personal Use q Legal
q Insurance
q Medical Treatment
q Medical Condition Verification q Disability q FMLA q Workers’ Comp
Check ONLY one of the following three options to identify the health information to be released.
q Option 1: Form Completion (a substitute form or relevant medical records may be released)
q Option 2: Last 2 years of Kaiser Permanente Medical Office and Kaiser Foundation Hospital records
q Option 3: Records as specified. You must complete Step 1 and Step 2 below.
Step 1. Enter date range or date(s) of the records to be released: _____________________________
Step 2. Select types of records to be released:
q KP Medical Office
q Kaiser Foundation Hospital q Immunization
q Lab Results
q Diagnostic Images
q Copays & Deductibles
q Itemized Billing q Pharmacy
q Other (provider, department, specialty): _________________________________________
NOTE: Hospital and Medical Office records released as part of this authorization may contain references
related to mental health, addiction, and HIV medical conditions.
Check the boxes below if you want this release to include the following information, Otherwise,
this information will be excluded.
q Mental Health Treatment Records q Addiction Medicine Treatment Records q HIV Test Results
Media Type: q Electronic
q Paper
Delivery Preference: q Electronic
q Mail
q Pickup
DURATION: Authorization shall remain in effect for one year from the date of signature below. However, in
Washington, D.C. permission to release addiction medicine treatment records expires after six (6) months.
REVOCATION: You or your personal representative may cancel this authorization for future releases by submitting
a written request to the Release of Information Unit listed for your region of service on the reverse side of this form.
Your cancellation will not affect information that was released prior to receipt of the written request.
REDISCLOSURE: Once this information is released, it may not be protected under federal privacy law (HIPAA).
State or other federal law may require the recipient to obtain your authorization before further disclosure.
Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benefits on whether you sign
this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization, and a
note stating to whom your information was disclosed will be included in your medical record. A copy of the original
authorization is valid. You have a right to a copy of this completed authorization.
Date
Signature
If personal representative, print name/relationship
NS-9934 (9-15) SPANISH-NS-1614; CHINESE-NS-6274
ORIGINAL - DISCLOSING PARTY
CANARY - PATIENT
NCAL: 90258 (REV. 9-15) SPANISH 01782-000; CHINESE 01782-002