Form La/1201706.4 - Authorization For Use And Disclosure Of Pharmacy Prescription Information

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AUTHORIZATION FOR USE AND DISCLOSURE OF
PHARMACY PRESCRIPTION INFORMATION
Kaiser Permanente will not condition treatment, payment, enrollment or eligibility for benefits on providing, or
refusing to provide this authorization
I hereby authorize: Kaiser Permanente Pharmacy (KFH and/or KFHP):
To disclose to:
My prescription records/information:
Print Name of Recipient
Print Name of Member / Patient
Address
Medical Record Number
City
State
Zip
Date of Birth
SPECIFY THE PRESCRIPTION INFORMATION TO BE USED OR DISCLOSED:
 All pharmacy records dated from: ____________________ to __________________
 Record of a specific prescription: _____________________ dated from _______________ to ______________
 Protected Minor Records (Adolescent Confidential). Only applicable if member / patient is 12-17 years old.
 Medical Expense Detail (“Tax Summary”) dated from __________________ to __________________
 Other (specify): __________________________________________________________________________
NOTE: Pharmacy records indicating treatment related to mental health, alcohol/drug treatment, HIV/AIDS status
and/or genetic information will not be disclosed unless specifically authorized below.
SIGNATURES AND DATES REQUIRED IF ANY OF THE FOLLOWING BOXES ARE CHECKED:
 Mental Health dated from
___________ to __________ Signature: ___________________ Date: __________
 Alcohol / Drug dated from
___________ to __________ Signature: ___________________ Date:__________
 HIV/AIDS Status dated from
___________ to __________ Signature: ___________________ Date: __________
 Genetic Information dated from ___________ to __________ Signature: ___________________ Date: __________
PURPOSE: The pharmacy records and information disclosed may only be used for the following
purpose(s): ____________________________________________________________________________.
DURATION: This authorization shall remain in effect for one year from the date of my signature below
unless a different date is specified here ______________ (date).
REVOCATION: You or your personal representative can revoke this authorization upon written request.
If you revoke, it will not affect information disclosed before the receipt of your written request to revoke.
CHARGES: I understand that I may be charged reasonable clerical costs and that you may charge a copy or other fee
associated with this request. I agree to pay these costs prior to receipt of the requested information.
REDISCLOSURE: I understand that information disclosed pursuant to this authorization may no longer be protected
under federal privacy law (HIPAA) and could be re-disclosed by the recipient. However, California law may prohibit the
recipient's re-disclosure of my information.
A copy of this authorization is as valid as the original. I have the right to receive a copy of this authorization.
Date
Signature
If Signed by Other than Member/Patient, Indicate Relationship
Mail or deliver form and copy of required documentation to: NPCO Records Desk, 12254 Bellflower Blvd, Downey CA 90242.
VERIFICATION OF SIGNEE'S IDENTITY (For Internal Use Only)
Date:
The identity of the Member / Patient or Personal Representative was verified using the attached:
Driver's License
Other Photo Identification
Notarized Document
Other
The legal authority of Personal Representative (if applicable) was verified using the attached:
Letters of Guardianship
Letters of Conservatorship
Power of Attorney
Other
LA/1201706.4
upd 10.17.2012 npco

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