Consent To Disclose Personal Health Information Form
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1Consent to Disclose Personal Health Information
Help us communicate with you better.
Please use this form to tell us when you would like us to leave messages or discuss your health with others, and
how we should contact you with non-urgent news such as lab results or appointment reminders. If you are
completing this form on behalf of another member/patient (i.e. a minor child), please use the member’s/patient’s
information.
What name I prefer to be called: _________________________________________
1.
How I like to get routine messages
2.
(please circle only one):
Letter
Secure Email through
Phone:_________________
Fax:____________________
When it is okay to leave a message about my health:
3.
(In the case of urgent news, we will always strive to reach you directly.)
Never
On my voicemail at home. Number: ___________________________________________________
On my voicemail at work. Number: ___________________________________________________
On my voicemail on mobile phone. Number: ____________________________________________
Who it is okay to discuss my health with:
4.
No one
Any of the people listed below:
______________________________/_______________________________/________________________
Name
Relationship
Phone Number
______________________________/_______________________________/________________________
Name
Relationship
Phone Number
What is okay to discuss or leave a message about:
5.
Any information about my treatment*, OR:
Laboratory results
Medical instructions or advice
Prescription drug information
X-ray reports
Eyeglasses or contact lens information
Appointment information, including type of appointment
Other (specify): ______________________________________________________________________
*This may include detailed personal medical information including medical services to be provided,
notification that items such as refills are ready for pick-up, as well as any information listed in #5 above.
_______________________________________________
_____________________________
Patient’s Name
Kaiser Permanente ID Number
_______________________________________________
_____________________________
Signature of Patient or Authorized Personal Representative
Date
(Attach legal documentation of authority)
This consent will remain in effect until revoked by the patient/representative, or in the case of a minor, on
the date the minor becomes an adult under state law. Please advise us of any changes to your preferences.
This form does not apply to behavioral health information.
For Office Use: Verification of Photo ID______________________ Verified By_____________________
Forward to: Release of Information Department
th
11000 E. 45
Avenue, Denver, CO 80239-3004
Rev. November 2013
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Parent category: Business