Authorization For Use Or Disclosure Of Patient Health Information Form

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Patient Name: ________________________________
Kaiser Foundation Health Plan of Colorado (KFHP) and/or
Kaiser # ___________________ Date of Birth: _______
The Colorado Permanente Medical Group (CPMG)
Address: _____________________________________
Send to: Release of Information Department
11000 E. 45
Ave., Denver, CO 80239-3004
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City: _________________________________________
Phone: 303-404-4700 / Fax: 303-404-4750
State: ____________________ Zip Code: __________
AUTHORIZATION FOR USE OR
Telephone Number: ____________________________
DISCLOSURE OF PATIENT HEALTH
INFORMATION
Kaiser Permanente may disclose health information to:
Check if same as above (disclosure to patient)
Recipient Name: ____________________________________________________________________________
Address: _________________________________City: ____________________State: _____Zip: ___________
Phone: ________________
This disclosure is limited to the following purpose(s):____________________________________________
Note: Kaiser Permanente utilizes an electronic health record to document all care received in this region. The
entire electronic record will be considered authorized for release, unless disclosure is limited to the selections
specified below. Fees may apply to certain requests.
This authorizes Kaiser Permanente to disclose the following protected health information:
All Medical Office Records
Limited to the following date range: ____________________ to ____________________
Limited to a specific provider: ________________
or department: _____________
X-Ray Reports
Laboratory Results
NOTE: Medical Office records may include references to your treatment for mental health, alcohol/drug
abuse, and/or HIV. I understand that my authorization above covers disclosure of any such references
contained within those records.
The actual treatment records from mental health, or addiction medicine departments, or results of HIV
antibody tests will not be disclosed unless you sign below.
Mental Health department records
 Signature: _________________________________________
Addiction Medicine treatment records
 Signature: _________________________________________
HIV/AIDS test results
 Signature: _________________________________________
Genetic testing
 Signature: _________________________________________
Media Type:
Electronic (<< electronic is preferred)
Paper
Delivery Preference:
Mail
Pickup
DURATION:
I understand this authorization will expire, without my expressed revocation, upon the earlier
of one year from the date of signing, or the date the minor child becomes an adult under
state law.
REVOCATION:
You or your representative can revoke this authorization upon written request sent to:
Release of Information Department, 11000 E. 45
Ave., Denver, Colorado 80239-3004.
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Your revocation will not affect information disclosed before the receipt of the written request.
REDISCLOSURE: Once this health information is disclosed, the information may no longer be protected under
federal privacy law (HIPAA) from re-disclosure.
Kaiser Permanente will not condition treatment, payment, enrollment or
eligibility for benefits on your providing, or refusing to provide, this authorization.
A copy of this authorization is as valid as an original. I have the right to receive a copy of this authorization.
_____________
__________________________________
____________________________________
Date
Signature
If not patient print your name and relationship

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