Kaiser Medical Records Fax Number Southern California Details

If you have ever wanted to access your medical records from Kaiser Permanente, you will need to fill out and submit a Kaiser Records Request Form. This form is used to request copies of your medical records, billing information, and other documentation from Kaiser Permanente. The process for requesting your records may vary depending on the location where you receive care from Kaiser Permanente, so be sure to check with your local health care facility for specific instructions. In general, you will need to provide your name, date of birth, contact information, and select the type of records you would like to receive. You may also be asked to provide authorization for the release of your information.

You'll find it helpful to know how much time you'll need to complete this kaiser records request and how long the form is.

QuestionAnswer
Form NameKaiser Records Request
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameskaiser release of medical records, kaiser release of information form, kaiser records request california, kaiser records request southern california

Form Preview Example

KAISER PERMANENTE

Kaiser Foundation Hospital

Southern California Permanente Medical Group

AUTHORIZATION FOR RELEASE AND / OR DISCLOSURE OF MEDICAL INFORMATION

IMPRINT KAISER PERMANENTE ID CARD HERE

Treatment, payment, enrollment or eligibility for benefits will not be conditioned on my providing or refusing to provide this authorization.

Please REQUEST Medical Information FROM:

Please SEND Medical Information TO:

Name of Health Care Provider

Name of Medical Office/Hospital

Street Address

City, State and Zip Code

Name of Person or Entity to Receive Information

Title (Physician, Therapist, Attorney)

Street Address

City, Slate and Zip Code

I hereby authorize

 

 

 

 

 

 

 

 

to release and / or disclose the medical

 

information as indicated below

to the health

care provider,

entity, or person I have indicated above.

 

Release and / or disclose records and information regarding:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Patent (List Other Names Used)

 

 

 

 

 

Medical Record Number

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

City

State Zip Code

 

Telephone Number

 

DURATION:

This authorization shall become effective immediately and shall remain in effect

 

 

until

 

(ENTER DATE) or for one year from the date of signature if no date entered.

 

REVOCATION: This authorization may be revoked in writing by the undersigned at any time prior to the release of information from the disclosing party. Written revocation will not affect any action

taken in reliance on this authorization before the written revocation was received.

REDIS- CLOSURE:

SPECIFY

RECORDS TO BE RELEASED AND / OR DISCLOSED:

I understand that the requester may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless disclosure is specifically required or permitted by law.

Check the box and initial which type of information is to be released and / or disclosed:

General Medical Information (FROM

 

 

 

 

 

TO

 

 

 

TO

 

 

 

Information Regarding Specific Injury or Treatment (FROM

 

 

 

)

X-Ray (check one or both):

 

 

 

 

 

 

Films

 

Reports

 

 

 

 

 

 

 

Laboratory Results

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental Health (FROM

 

 

 

 

TO

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Patient or Patient's Representative

 

Date

Alcohol / Drug (FROM

 

 

 

TO

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Patient or Patient's Representative

 

Date

HIV TEST RESULTS (FROM

 

 

TO

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Patient or Patient's Representative

 

 

Date

Other (specify):

I request that the health information released and / or disclosed pursuant to this authorization be used for the following purposes only:

A copy of this authorization is valid as an original.

I have the right to receive a copy of this authorization. The copy is for me to keep.

Date

 

Signature of Patient or Patient's Representative

 

Indicate Relationship (if Signed by Other than Patient)

NS-9934 (10-03) HIPAA COMPLIANCE:

ORIGINAL-DISCLOSING PARTY CANARY-CHART PINK-PATIENT

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