Authorization For Use Or Disclosure Of Patient Health Information Form

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Patient Name: ______________________________
Kaiser # _______________ Date of Birth: _________
Kaiser Foundation Hospitals
Address: ___________________________________
Permanente Medical Groups
City: ______________________________________
AUTHORIZATION FOR USE OR DISCLOSURE
State: __________________ Zip Code: __________
OF PATIENT HEALTH INFORMATION
Phone #: __________________________________
(
)
Note: Fees may apply to certain requests
Email: _____________________________________
Kaiser Permanente will not condition treatment, payment, enrollment or
eligibility for benefits on providing, or refusing to provide this authorization.
This authorizes the following Kaiser Permanente
Kaiser Permanente may disclose this information to:
Medical Center(s): __________________________
q Check if same as above (disclosure to patient)
__________________________________________
Recipient Name: ____________________________
Address: ___________________________________
to disclose information as specified below for the
City: ______________________________________
following purpose(s): _________________________
State: __________________ Zip Code:___________
__________________________________________
__________________________________________
Phone #: ______________ Fax #: ______________
(
)
(
)
__________________________________________
Email: _____________________________________
Copies of records or medical record information within the following dates: _________ to _________
q Both Hospital and Medical Office Records
q Medical Office Records
q Hospital Records
q Records limited to a specific provider: ___________________ or department: _____________________
q X-Ray films
q X-Ray Digital Images
q Laboratory Results
NOTE: Hospital and Medical Office records may include disclosure of information related to mental
health, alcohol/drug, and HIV references contained within those records as part of this authorization.
The actual treatment records from mental health, or alcohol/drug departments, or results of HIV
antibody tests are specifically protected, and will not be disclosed unless you sign below.
Mental Health department records
Signature: ____________________________________
Alcohol / Drug dependency treatment records
Signature: ____________________________________
HIV antibody test results
Signature: ____________________________________
Media Type: q Electronic
Delivery Preference: q Email/Secure Portal
q Paper
q Mail
q Pickup
DURATION:
This authorization shall remain in effect for one year from the date of signature unless a
different date is specified here _______________(date).
REVOCATION:
You or your representative can revoke this authorization upon written request. If you
revoke, it will not affect information disclosed before the receipt of the written request.
REDISCLOSURE: Once this health information is disclosed, how the recipient further discloses it may no
longer be protected under federal privacy law (HIPAA). California recipients are
required to obtain your authorization before further disclosing this information.
If you are requesting a form to be completed, we may substitute a standardized version of the form that
provides the same or similar information requested.
A copy of this authorization is as valid as an original. I have the right to receive a copy of this authorization.
Date
Signature
If not patient, print your name and relationship
SCAL: NS-9934 (6-12) SPANISH-NS-1614; CHINESE-NS-6274
NCAL: 90258 (REV. 6-12) SPANISH 01782-000; CHINESE 01782-002
ORIGINAL - DISCLOSING PARTY
CANARY - PATIENT

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