Do you have questions about your healthcare coverage? Do you need to access the Kaiser Permanente health care forms? Whether this is your first time needing to fill out a form or if you are an experienced user, understanding what information is required and what procedures are involved can be difficult. The purpose of this blog post is to help guide you through the steps necessary in order to complete the Kaiser Permanente Health Information Form. We will discuss why filling out such forms are important, as well as provide helpful tips and tricks for smooth processing when dealing with Kaiser Permanente's paperwork. Continue reading for more information!
| Question | Answer |
|---|---|
| Form Name | Health Information Kaiser Permanente Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | disclose information kaiser, medical kaiser disclosed, authorization disclose health information kaiser, health permanente information kaiser |
Kaiser Foundation Hospitals
The Permanente Medical Group, Inc.
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION TO KAISER PERMANENTE
MR #:
Name:
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IMPRINT AREA |
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I hereby authorize: |
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to disclose to: |
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Kaiser Permanente at |
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Provider or Clinic |
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Location |
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Street Address
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Name of Provider |
Street Address |
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City |
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Records and information pertaining to:
Patient Name |
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Date of Birth |
Daytime Phone |
Medical Record Number |
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Street Address |
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City |
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State |
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ZIP |
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The type and amount of information to be disclosed is as follows (specify dates where appropriate):
■ Most recent 2 years of record for adult patients |
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■ Pediatric Record for minor patients |
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■ Immunization Record |
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■ Radiology Reports, from date |
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to |
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■ Radiology Images (exam/date): |
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■ All Breast Images and Breast Imaging Reports |
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■ Laboratory Results, from date |
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to |
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■ Other records not listed (specify): |
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1.I understand that the medical information released may include any and all information concerning treatment of medical history, mental illness, alcohol/drug abuse, and HIV/AIDS information.
2.I understand that although disclosure of health information for treatment purposes from provider to provider is generally considered a professional courtesy, a health care provider may charge me a fee for disclosure of this health information.
3.I understand that a Kaiser Permanente provider may review the records to determine what content ultimately becomes part of the patient’s Kaiser Permanente medical record.
PURPOSE: The health information disclosed will be used for continuing care/treatment purposes.
DURATION: This authorization shall remain in effect for one year from the date of signature unless a
different date is speciied 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.
A copy of this authorization is as valid as the original. I have a right to a copy of this authorization.
Signature of Patient or Personal Representative |
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Personal Representative’s Name Print) and Relationship |
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DISTRIBUTION: WHITE = CHART • CANARY = MEMBER/PATIENT |
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