0004-1756 9/13 Privacy & Security White: OPMR – Scan Yellow - Patient
Kaiser Foundation Health Plan of the Northwest • Kaiser Foundation Hospitals
Authorization for Kaiser Permanente to
Use/Disclose Protected Health Information
NICKNAME / MAIDEN NAME / OTHER
DATE OF BIRTH (MO/DAY/YR)
( )
ADDRESS STREET OR BOX NUMBER
I authorize Kaiser Permanente to release the following information for: ___________________________________________
NAME OF PERSON TO RECEIVE INFORMATION
TITLE (PHYSICIAN, ATTORNEY, ETC.) PHONE NUMBER
STREET ADDRESS CITY STATE ZIP CODE
The purpose or need for the exchange and disclosure of this information is to:
1)
F
acilitate treatment; 2) Summarize treatment and/or; 3) Facilitate billing/reimbursement from insurance carriers.
Description of information to be used/disclosed (Be as specific as possible):
All records
X-ray films (describe): ______________________________________________________________
Other (describe): ___________________________________________________________________
Media Type: Delivery Preference:
Electronic Paper Email/Secure Portal Pickup Mail
If the information to be used/disclosed contains any of the types of records or information listed below, additional laws
relating to the use and disclosure of the information may apply. I understand and agree that this information will be used or
disclosed if I place my initials in the applicable space next to the type of information:
______Drug/Alcohol diagnosis, treatment or referral information ______HIV/AIDS information
______Mental Health information – including provider notes ______Genetic testing information
I understand that the information used or disclosed pursuant to this authorization may be subject to redisclosure and no longer
be protected under federal law. However, I also understand that federal or state law may restrict redisclosure of drug/alcohol
diagnosis, treatment or referral information, mental health information and genetic testing information.
Kaiser Permanente will not condition treatment, payment, enrollment, or eligibility for benefits on providing, or refusing to
provide this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care
services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care
service is if the health care services are solely for the purpose of providing health information to someone else and the
authorization is necessary to make that disclosure.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above
may no longer be used or disclosed for the purposes described in this written authorization. Any use or disclosure already
made with your permission cannot be undone. To revoke this authorization, please send a written statement to Kaiser
Permanente, Release of Information Department at 10220 SE Sunnyside Rd., Clackamas, Oregon 97015 and state that you
are revoking this authorization. To revoke this authorization orally, please call Release of Information Department at
503-571-5051 and state that you are orally revoking this authorization.
I have read this authorization and understand it. Unless revoked, this authorization expires in 12 months. In
Washington, this authorization shall expire 90 days after the date signed if disclosure is to a financial institution or an
employer for purposes other than payment.
A copy of this authorization is valid as an original. Member/patient has a right to a copy of this authorization.
X___________________________________________________ X_____________________________________
SIGNATURE OF INDIVIDUAL OR PERSONAL REPRESENTATIVE DATE
X___________________________________________________
DESCRIPTION OF PERSONAL REPRESENTATIVE’S AUTHORITY
1. Member must complete this section
