Authorization To Use And/or Disclose Protected Health Information Form (Page 2 of 2) in pdf

Stapleton Support Services

11000 E. 45

Avenue, Denver, CO 80239-3004

TTY: 1-800-659-2656

NOTE: I understand that the medical information released by this authorization may include information

concerning treatment of physical or mental illness, past medical history, alcohol/drug abuse, HIV/AIDS, or other

sensitive information.

I am requesting that Kaiser Permanente release these records in the following format:

Paper format or

Electronic copies on CD (only

applies to records maintained by Kaiser Permanente in

electronic medical record)

______________________________________________________

_____________________________

Patient Name (please print)

Medical Record Number

I understand this authorization will expire, without my expressed revocation, either one year from the date of

signing, or the date the minor child becomes an adult according to state law, whichever occurs first. I

understand that I may revoke this authorization by sending a request in writing to the address at the top of this

form, except to the extent that action has been taken based on it. I understand that revocation will not apply to

information that has already been released as specific by this authorization or to my insurance company when

the law provides my insurer with the right to contest a claim under my policy or the policy itself.

I understand that Kaiser Permanente will only release requested records up to the date of my signature, and

does not include future records. If I request to have records disclosed in the future, I will be required to

complete a new authorization.

I understand that authorization for the disclosure of this health information is voluntary and I can refuse to sign

this authorization. KFHP/CPMG cannot condition treatment, payment, or enrollment in the health plan or

eligibility for benefits on the signing of an authorization, except as otherwise permitted by law. I understand

that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the

receiving party, which may not be protected by federal confidentiality rules.

_______________________________________________________

______________________________

Signature of Patient or Authorized Personal Representative

Date

________________________________________________________________________________________

Personal Representative’s Name and Relationship (please attach applicable legal documentation of authority)

For Kaiser Permanente Office Use Only: Verification of Photo Identification

ID# and State ______________________________________ Verified by:_______________________________

Page 2 of 2

CONFIDENTIAL

October 2011

Authorization To Use And/or Disclose Protected Health Information Form Page 2