Form Ns-9934 - Authorization For Release And / Or Disclosure Of Medical Information - Kaiser
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1Kaiser Foundation Hospitals
Southern California Permanente Medical Group
AUTHORIZATION FOR RELEASE AND / OR
DISCLOSURE OF MEDICAL INFORMATION
IMPRINT KAISER PERMANENTE ID CARD HERE
Treatment, payment, enrollment or eligibility for benefits will not be conditioned on my providing or refusing
to provide this authorization.
Please SEND Medical Information TO:
Please REQUEST Medical Information FROM:
c/o RONSIN
PHOTOCOPY INC
Name of Health Care Provider
Name of Person or Entity to Receive Information
Name of Medical Office/Hospital
Title (Physician, Therapist, Attorney)
Street Address
Street Address
City, State and Zip Code
City, State and Zip Code
I hereby authorize _________________________________ to release and / or disclose the medical
information as indicated below to the health care provider, entity, or person I have indicated above.
Release and / or disclose records and information regarding:
_____________________________________________________________
__________________________
______________
Name of Patient (List Other Names Used)
Medical Record Number
Date of Birth
(
)
____________________________________________________________________________
____________________________
Address
City
State Zip Code
Telephone Number
This authorization shall become effective immediately and shall remain in effect
DURATION:
until ___________( enter date ) or for one year from the date of signature if no date entered.
This authorization may be revoked in writing by the undersigned at any time prior to the
REVOCATION:
release of information from the disclosing party. Written revocation will not affect any action
taken in reliance on this authorization before the written revocation was received.
I understand that the requester may not lawfully further use or disclose the health information
REDIS-
:
unless another authorization is obtained from me or unless disclosure is specifically required
CLOSURE
or permitted by law.
Check the box and initial which type of information is to be released and / or disclosed:
SPECIFY
General Medical Information (from______ to _____ )
RECORDS
Information Regarding Specific Injury or Treatment (from______ to _____ )
TO BE
X-Ray (check one or both):
Films
Reports
RELEASED
Laboratory Results
AND / OR
Mental Health (from_____ to _____ )
________________________ ________
DISCLOSED:
Signature of Patient or Patient’s Representative
Date
Alcohol / Drug (from_____ to _____ ) ________________________ ________
Signature of Patient or Patient’s Representative
Date
HIV Test Results (from_____ to ____ ) ________________________ ________
Signature of Patient or Patient’s Representative
Date
Other (specify): ___ _________________________________________________
I request that the health information released and / or disclosed pursuant to this authorization
be used for the following purposes only: ____________________________________________
_________________________________________________________________________________________
A copy of this authorization is valid as an original.
I have the right to receive a copy of this authorization. The copy is for me to keep.
_____________
____________________________
______________________________
Date
Signature of Patient or Patient’s Representative
Indicate Relationship (if Signed by Other than Patient)
NS-9934 (10-03) HIPAA COMPLIANCE
ORIGINAL-DISCLOSING PARTY
CANARY-CHART
PINK-PATIENT
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