Home > Life > Medical Forms > Medical Records Release Template > California Medical Records Release Form > California Authorization For Disclosure of Patient Health Information

California Authorization For Disclosure of Patient Health Information

At Speedy Template, You can download California Authorization For Disclosure of Patient Health Information . There are a few ways to find the forms or templates you need. You can choose forms in your state, use search feature to find the related forms. At the end of each page, there is "Download" button for the forms you are looking form if the forms don't display properly on the page, the Word or Excel or PDF files should give you a better reivew of the page.
This form is provided by Kaiser Foundation Hospitals Permanente Medical Groups to authorize the disclosure or release of one person's protected health information.

California Authorization For Disclosure of Patient Health Information
California Authorization For Disclosure of Patient Health Information
This authorizes the following Kaiser Permanente
Medical Center(s): __________________________
__________________________________________
Patient Name: _____________________________
Kaiser # _______________ Date of Birth: ________
Address: __________________________________
City: _____________________________________
State: __________________ Zip Code: _________
Telephone Number: _________________________
Email: ____________________________________
Note: Fees may apply to certain requests
AUTHORIZATION FOR USE OR DISCLOSURE
OF PATIENT HEALTH INFORMATION
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
Kaiser Foundation Hospitals
Permanente Medical Groups
NS-9934 (2-11) HIPAA COMPLIANT SPANISH-NS-1614; CHINESE-NS-6274
90258 (REV. 2-11) SPANISH 01782-000; CHINESE 01782-002
Kaiser Permanente will not condition treatment, payment, enrollment or
eligibility for benefits on providing, or refusing to provide this authorization.
To: q Produce a copy of medical records as
speciedbelow
q Complete form(s) (Please specify form
type(s)inthePURPOSEsectionbelow)
qAllownamedKPphysiciantoviewrecords
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OfceRecordsdatedfrom__________to__________
qHospital Records dated from __________ to __________
NOTE: Hospital and medical ofce 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 specically 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
Specic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Condential).Onlyapplicableforpatientrequesters12-17yearsold.
DURATION:
Thisauthorizationshallremainineffectforoneyearfromthedateofsignatureunlessa
differentdateisspecied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.
( )
Media Preference: qPaper qCD(ifavailableelectronically)Delivery Preference: qMail qPickupqFaxqEmail
Date Signature Ifnotpatient,printyournameandrelationship
Kaiser Permanente may disclose this information to:
Recipient Name: ___________________________
Address: _________________________________
City: _____________________________________
State: __________________ Zip Code: _________
Telephone number: _________________________
Faxnumber:_______________________________
Email: ____________________________________
( )
( )
California Authorization For Disclosure of Patient Health Information