Kaiser permanente authorization for use or disclosure of patient health information

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Cal ifor n ia. Col or ado. Geor gi a. Print nam e, ad dr ess , phone nu mber , fax number and email address. Delivery method : Electronic delivery is recommended. Check the box th at applies to the reason the r ecor ds ar e being requested. Medic al r ecor ds — a max im um of 10 ye ars of rec or ds.

Billing records — p r emi um payment s n ot included. Sign and d ate. P erson al r eprese ntat ive s houl d pr int nam e and i ndicat e rel atio nsh ip to th e pat ient. Documentation may be required to prove au thority to sign on behalf of the patient.

Mi nor p at ie nts age s 13 to 17 m ust aut hori ze the r elease of infor mat ion rel ated to. If no dat e or event is given, auth ori zatio n will expir e 90 days from date signed. To subm it your r equest, pleas e fax y our comple ted for m to the appr opr iate lo cati on s list e d bel ow. Pleas e vis it our websit e. Weste rn Washington.

Kaiser Foundatio n Health Plan of Washingt on. Releas e of Informat ion. PO Box Renton, WA 7 - Phone: - - 8 or toll - free 1 - - - Hours : 8 a.

Fax: 20 6 - - Eastern Washingt on. Kai ser F ound atio n Health Pl an of Wash ingt on. Health Information M anagement. Spokane, WA 9 - Phone: - - Hours: 8 a. Fax: - - Kai ser F oundat ion Health Plan of W ashin gton.

Washingto n, this authoriz ation shall expire 90 days after the date signed if disclosure is to a financial institution o r an. A copy of th is auth orizati on is valid as an origin al.

Member must complete this section. Instructi ons. I f not complete, form may be sent back to you. C omplete each. If none, leave this box blan k. State the purpose for the release o f information. Ex amples: Insurance application, Insurance Claim,. Legal, Benefits, Schoo l, P atie nt Care , e tc. For my own purposes may be used only if you a re. W ri te the name or comp any of who is to receive t he information.

Examples: Attorn ey, Physician, etc. Circle the purpose or ne ed for the exchange and disclosure of this information. Check the box es that apply to your request:. Examples: All. Please indicate media type and deliv ery preference. If no options are checked, the default will be paper. Sign the authorization. If y ou are not the patient, describe your relationshi p and legal authority to sign. You will be required to pr ovide the legal paperwork.