Authorization To Use And/or Disclose Protected Health Information Form

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Stapleton Support Services
th
11000 E. 45
Avenue, Denver, CO 80239-3004
TTY: 1-800-659-2656
Authorization to Use and/or Disclose Protected Health Information
Release of Information
•
Phone: 303-404-4700
•
Fax: 303-404-4750
X
I authorize Kaiser Foundation Health Plan of Colorado (KFHP) and/or the Colorado Permanente
Medical Group (CPMG) to release the health information of the individual named below.
I authorize my previous Health Care Provider to release the health information of the individual named
below, to the Kaiser Foundation Health Plan of Colorado (KFHP) and/or the Colorado Permanente
Medical Group (CPMG). Please fax to Data Integrity Department, at 303-404-4850, or mail to the
address listed above.
___________________________________________________
______________________________________
Patient Name
Medical Record Number
____________________________________________________________________________________________
Street Address
City
State
ZIP
__________________________
_____________________
Phone number
Date of birth
KAISER PERMANENTE
I hereby authorize: ____________________________________ (Name of sending person/organization)
11000 E. 45TH AVE
DENVER
CO
80239
____________________________________________________________________________________________
Street address
City
State
ZIP
(303) 404-4700
X
____________________________________ Method:
Pick up in person
Mail
Fax
Phone Number
EIS PROCESSING CENTER
To disclose to the following individual or organization: _____________________________________
P.O. BOX P
TORRANCE
CA
90508
____________________________________________________________________________________________
Street address
City
State
ZIP
(888) 846-8804
__________________________
**Kaiser Permanente will bill the receiving party or
Phone number
organization for charges related to the copies of the
records. Patients will not be billed for these charges.
Purpose of Use or Disclosure
FMLA/LOA
Narrative
Employer Request
Personal Use
Continuity of Care
X
Return to Work
Insurance
Social Security
Attorney
Workers Compensation
Other (Specify): ______________________________________________________________________
The type and amount of information to be disclosed is as follows (specify dates):
Immunizations
Laboratory Results:
/
/
to
/
/_____
X
5
Most recent _____ (years) of record
X-Ray Reports:
/
/
to
/
/_____
Entire medical record
FMLA/Return to work paperwork
Other (Specify): ___________________________________________________________________________
Page 1 of 2
CONFIDENTIAL
October 2011

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