Kaiser Permanente Form PDF Details

If you are a Kaiser Permanente member, you may be familiar with the organization's Form. This form is used to request medical care and services, and it can be used to document other information related to your health. In this blog post, we will provide an overview of the Kaiser Permanente Form, including its features and how to use it. We will also discuss some tips for completing the form correctly.

In the table, there is some good information relating to the kaiser permanente form. You may want to learn its size, the typical time needed to complete the form, the blanks you'll need to fill in, and so on.

QuestionAnswer
Form NameKaiser Permanente Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namespermanente claim form, kaiser permanente submit claim form, kaiser claim medical, permanente claim

Form Preview Example

(*Kaiser Permanente entities are listed on reverse side of this form)

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION

Note: Fees may apply to certain requests

Patient Name:

Medical Record Number:

 

Birth Date:

 

Address:

 

 

 

 

 

 

 

 

City:

 

 

State:

 

 

 

 

 

 

 

 

 

Zip Code:

 

_ Phone #: (

)

Email:

 

 

 

 

 

 

 

 

Kaiser Permanente may release this information to: q Check if same as above

Recipient Name: __________________________________________________________________

Address: ______________________________ City:______________ State:______ Zip Code:_______

Phone # (

)

Email: ___________________________________

 

 

 

 

 

 

This disclosure can be used for the following purpose(s): q Personal Use

q Legal q Insurance

q Medical Treatment

q Medical Condition Verification q Disability

q FMLA qWorkers’ Comp

 

 

 

 

Check ONLY one of the following three options to identify the health information to be released.

qOption 1: Form Completion (a substitute form or relevant medical records may be released)

qOption 2: Last 2 years of Kaiser Permanente Medical Office and Kaiser Foundation Hospital records

qOption 3: Records as specified. You must complete Step 1 and Step 2 below.

Step 1.

Enter date range or date(s) of the records to be released: _____________________________

Step 2.

Select types of records to be released:

 

 

 

q KP Medical Office

q Kaiser Foundation Hospital

qImmunization

q Lab Results

 

q Diagnostic Images

q Copays & Deductibles

qItemized Billing

q Pharmacy

qOther (provider, department, specialty): _______________________________________

NOTE: Hospital and Medical Office records released as part of this authorization may contain references related to mental health, addiction, and HIV medical conditions.

Check the boxes below if you want this release to include the following information, Otherwise, this information will be excluded.

q Mental Health Treatment Records

qAddiction Medicine Treatment Records

qHIV Test Results

For records from Kaiser Permanente Oregon locations only, Genetic Testing information will not be included unless you check this box q

Media Type: q Electronic q Paper

Delivery Preference: q Electronic q Mail

q Pickup

 

 

 

 

DURATION: Authorization shall remain in effect for one year from the date of signature below. However, in Washington, D.C. permission to release addiction medicine treatment records expires after six (6) months.

REVOCATION: You or your personal representative may cancel this authorization for future releases by submitting a writ- ten request to the Release of Information Unit listed for your region of service on the reverse side of this form. Your cancel- lation will not affect information that was released prior to receipt of the written request.

REDISCLOSURE: Once this information is released, it may not be protected under federal privacy law (HIPAA). State or other federal law may require the recipient to obtain your authorization before further disclosure.

Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benefits on whether you sign this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization, and a note stating to whom your information was disclosed will be included in your medical record. A copy of the original authorization is valid. You have a right to a copy of this completed authorization.

Date

 

Signature

 

 

If personal representative, print name/relationship

0004-1756 6/21 HIM_Regional Forms Committee last reviewed_5/21

ORIGINAL - DISCLOSING PARTY CANARY - PATIENT

“Kaiser Permanente” means both your insurance company (a Kaiser Permanente health plan) and your doctors (a Permanente medical or dental group). It also includes different groups depending on where you live.

You can contact all Kaiser Permanente regions via kp.org/requestrecords.

All states where we do business:

• Kaiser Foundation Hospitals

California:

Kaiser Foundation Health Plan, Inc., Northern California Region

The Permanente Medical Group

Kaiser Foundation Health Plan, Inc., Southern California Region

Southern California Permanente Medical Group

Colorado:

Kaiser Foundation Health Plan of Colorado

Colorado Permanente Medical Group, P.C.

Georgia:

Kaiser Foundation Health Plan of Georgia, Inc.

The Southeast Permanente Medical Group, Inc.

Hawaii:

Kaiser Foundation Health Plan, Inc., Hawaii Region

Hawaii Permanente Medical Group, Inc.

Mid-Atlantic States:

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Mid-Atlantic Permanente Medical Group, P.C.

Oregon and Southern Washington:

Kaiser Foundation Health Plan of the Northwest

Northwest Permanente, P.C.

Permanente Dental Associates, P.C.

Washington:

Kaiser Foundation Health Plan of Washington

Kaiser Foundation Health Plan of Washington Options, Inc.

Washington Permanente Medical Group, P.C.

Watch Kaiser Permanente Form Video Instruction

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