Kaiser Records Request PDF 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

Patient Name: __________________________________________

Medical Record Number: _________________________________

Birth Date: ___________ Email: ____________________________

Do not use for patient copies of or access to their medical records. Patients should go to kp.org/requestrecords to conveniently request medical records, FMLA and Disability certifications.

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION

To the Following Third-Party Recipient (Fees may be required)

Recipient Name: ______________________________________________________________________________

Address: ______________________________________________________________________________________

City: ___________________________________________________ State: ________ Zip Code: ______________

Phone # ( ______ ) __________________ Email: _____________________________________________________

This disclosure can be used for the following purpose(s): Legal Insurance Medical Certification Other

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

I authorize the following to be disclosed for the selected time frame:

Form Completion (a substitute form or relevant medical records may be released in lieu) Medical Records

 

Diagnostic Images

 

 

Itemized Billing Records

 

Pharmacy Copays

 

Medical Copays

 

 

 

 

Time Frame: Last

2 months

 

6 months

 

1 year

2 years

 

5 years

 

All electronic records

 

 

 

 

 

 

Check the boxes below if you want this release to include the protected treating department or HIV initial test result information. If not checked, this treating department information will be excluded.

Mental Health Treatment Records Addiction Medicine Treatment Records HIV Lab Test Results Kaiser Permanente Oregon locations need to also check this box if they want Genetic Testing information released.

DURATION: Authorization shall remain in effect for 6 months from the date of signature below.

REVOCATION: You or your personal representative may cancel this authorization for future releases by submitting a written request to the Release of Information Unit listed for your region of service found on kp.org/requestrecords. Your cancellation 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.

We will provide the requested information in electronic format to the recipient unless the recipient contact us to make other arrangements.

 

 

 

 

 

 

 

Date

 

Signature

 

 

If personal representative, print name/relationship

NS-9934 (08-21) SPANISH-NS-1614; CHINESE-NS-6274

ORIGINAL - DISCLOSING PARTY CANARY - PATIENT

Instructions:

1)Complete the patient identification information on the top right-hand corner

2)Complete all required information for the recipient including a valid email address

3)Check the box for purpose of disclosure

4)Check the box(es) for the type of information to be disclosed and also check the box for a timeframe

5)If you want specially protected information to be included, check the appropriate box(es)

6)Enter the date you are signing the authorization

7)Sign the form

8)If you are a personal representative, print your name and relationship. We may reach out for you to provide additional documentation if needed.

9)Submit this form to the third party you are authorizing to obtain records

10)Keep a copy for your records

“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.

To find contact information go to kp.org and search locations for your region/market listed below or alternatively go to kp.org/requestrecords and indicate your region/market.

All states where we do business:

Kaiser Foundation Hospitals

Kaiser Permanente Insurance Company

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.

Mid-Atlantic (Maryland/Virginia/Washington, D.C.):

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

Mid-Atlantic Permanente Medical Group, P.C.

Washington:

Kaiser Foundation Health Plan of Washington

Washington Permanente Medical Group, P.C.

Hawaii:

Kaiser Foundation Health Plan, Inc., Hawaii Region

Hawaii Permanente Medical Group, Inc.

Maui Health Systems

Northwest (Oregon/SW Washington):

Kaiser Foundation Health Plan of the Northwest

Northwest Permanente, P.C.

Permanente Dental Associates, P.C.

California - North:

Kaiser Foundation Health Plan, Inc., Northern California Region

The Permanente Medical Group, Inc.

California - South:

Kaiser Foundation Health Plan, Inc., Southern California Region

Southern California Permanente Medical Group

Patient Name: __________________________________________

Medical Record Number: _________________________________

Birth Date: ___________ Email: ____________________________

Do not use for patient copies of or access to their medical records. Patients should go to kp.org/requestrecords to conveniently request medical records, FMLA and Disability certifications.

AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION

To the Following Third-Party Recipient (Fees may be required)

Recipient Name: ______________________________________________________________________________

Address: ______________________________________________________________________________________

City: ___________________________________________________ State: ________ Zip Code: ______________

Phone # ( ______ ) __________________ Email: _____________________________________________________

This disclosure can be used for the following purpose(s): Legal Insurance Medical Certification Other

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

I authorize the following to be disclosed for the selected time frame:

Form Completion (a substitute form or relevant medical records may be released in lieu) Medical Records

Diagnostic Images

Itemized Billing Records Pharmacy Copays Medical Copays

Time Frame: Last

2 months 6 months 1 year 2 years 5 years All electronic records

Check the boxes below if you want this release to include the protected treating department or HIV initial test result information. If not checked, this treating department information will be excluded.

Mental Health Treatment Records Addiction Medicine Treatment Records HIV Lab Test Results Kaiser Permanente Oregon locations need to also check this box if they want Genetic Testing information released.

DURATION: Authorization shall remain in effect for 6 months from the date of signature below.

REVOCATION: You or your personal representative may cancel this authorization for future releases by submitting a written request to the Release of Information Unit listed for your region of service found on kp.org/requestrecords. Your cancellation 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.

We will provide the requested information in electronic format to the recipient unless the recipient contact us to make other arrangements.

 

 

 

 

 

 

 

Date

Signature

 

 

If personal representative, print name/relationship

NS-9934 (08-21) SPANISH-NS-1614; CHINESE-NS-6274

ORIGINAL - DISCLOSING PARTY CANARY - PATIENT

Watch Kaiser Records Request Video Instruction

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