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
Telephone Number: _________________________
(
)
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): __________________________
Recipient Name: ___________________________
__________________________________________
Address: _________________________________
City: _____________________________________
To: q Produce a copy of medical records as
specified below
State: __________________ Zip Code: _________
q Complete form(s) (Please specify form
Telephone number: _________________________
(
)
type(s) in the PURPOSE section below)
Fax number: _______________________________
(
)
q Allow named KP physician to view records
Email: ____________________________________
PURPOSE: The health information disclosed may only be used for the following purposes:
FOR COPIES, SPECIFY THE HEALTH INFORMATION NEEDED FOR USE OR DISCLOSURE
q Medical Office Records dated from __________ to __________
q Hospital Records dated from __________ to __________
NOTE: Hospital and medical office records may include information related to mental health,
alcohol/drug, and HIV references. The actual treatment records from mental health and/or alcohol/drug
departments, and/or results of HIV tests will not be disclosed unless specifically requested below.
SIGNATURES AND DATES REQUIRED IF ANY OF THE FOLLOWING BOXES ARE CHECKED
q Mental Health dated from ________ to _________ Signature: ______________________ Date:________
q Alcohol / Drug dated from ________ to _________ Signature: ______________________ Date:________
q HIV Test Results dated from ________ to ________ Signature: ______________________ Date:________
q Specific Injury/Treatment: ________________ Department: _______________ dated from ________ to ________
q X-Ray: q Images and/or Films q Reports Describe: ________________________________________
q Laboratory Results dated from ____________ to ____________
q Other (specify):_______________________________________________________________________________
q Protected Minor Records (Adolescent Confidential). Only applicable for patient requesters 12-17 years old.
Media Preference: qPaper qCD (if available electronically) Delivery Preference: qMail qPickup qFax qEmail
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).
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
NS-9934 (2-11) HIPAA COMPLIANT SPANISH-NS-1614; CHINESE-NS-6274
ORIGINAL - DISCLOSING PARTY
CANARY - PATIENT
90258 (REV. 2-11) SPANISH 01782-000; CHINESE 01782-002

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