Act For A Family Member, Access Authorization Form printable pdf download

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

2101 E. Jefferson Street, Rockville, MD 20849-6611

Act for a Family Member via Kaiser ()

Access Authorization Form

Diminished Capacity Individual’s Information:

I authorize Kaiser Permanente Foundation Health Plan and/or The Mid-Atlantic Permanente Medical Group, Inc. to

disclose protected health information via Kaiser for the patient named below:

Patient Name: _________________________________________ Medical Record #:___________________

Address: _______________________________________________________________________________

City/State/Zipcode: _______________________________________________________________________

Telephone #: (___) ________________________________

Patient’s Date of Birth _____/_____/________

Designated Proxy (Legal Representative) Information:

I authorize Kaiser Permanente Foundation Health Plan and/or The Mid-Atlantic Permanente Medical Group, Inc. to

disclose protected health information on Kaiser for the patient named below:

_______________________________________________

_______________________________________

Name of Person to Have Access

Kaiser Medical Record Number

Date of Birth: ______/______/____________

Telephone #: (_____)______________________

Relationship to Patient:

Legal Guardian**

Durable Power of Attorney for Health

HealthCare Agent Form

**If the Legal Guardian, Durable Power of Attorney for Health Care or a Healthcare Agent, a copy of the supporting documentation must be attached to

this form

Patient or Patient’s authorized legal representative must sign below

I understand that the information released upon authority of this authorization may include information regarding the

patient’s treatment for physical and mental illness, alcohol/drug abuse, HIV/AIDS test results, diagnosis or treatment of

HIV/AIDS, and past medical history information. I understand that I may discontinue online Act for a Family Member

access at any time by contacting the Health Information Management Services Department at any Medical Center in the

Mid-Atlantic. For this authorization to be valid, activation of the Act for a Family Member online access feature must

occur within 60 days from the date of signing this authorization form. I understand that this authorization shall be valid for

a period not to exceed two (2)

years.

This authorization may also be revoked at anytime in writing.

_________________________________________________

______________________________________

Signature of Patient or Authorized Legal Representative

Date

Return completed form and supporting legal documentation (if applicable) to:

Kaiser Permanente

Health Information Management Services Department

*******************************************For Kaiser Permanente Internal Use Only**************************************

Approved – Diminished Capacity Patient

Not Approved – Patient does not have diminished capacity

Verified by Primary Care Physician Name:___________________________________ Date:______________

Processed by: _____________________________________

Date Completed: ___________________

00349501 (7/08)

Act For A Family Member, Access Authorization Form

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