Fillable HEALTH INFORMATION EXCHANGE OPT IN REQUEST FORM

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HEALTH INFORMATION EXCHANGE OPT IN REQUEST FORM

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NS-11374 (06 -20)
Georgia Region
HEALTH INFORMATION EXCHANGE
OPT IN REQUEST FORM
Original: 07/26/2013 Revised: 7/9/2020
MR #:
Name:
Sex /.BD:
I previously submitted a request to “Opt-Out” of having my information shared electronically by
Kaiser Permanente Georgia Region (KPGA) and now request that I be reinstated so that my health
information can be electronically accessed through an HIE network by authorized health care
providers.
A separate form must be completed by each family member wishing to Opt-In. Please complete
all of the below required fields for accurate processing.
Patient Name
(print)
Health
Record #
Date of
Birth
Mailing Address Telephone
#
X Signature (Required) ______________________________________ Date ___ | ___ | _____
If signed by someone other than the patient, please print name below and indicate relationship.
Submit documents to show authority.
Print Authorized Representative’s Name Relationship to patient
Once this form is complete, please mail to:
Medical Records Administration / 400 Dekalb Tech Parkway / Bldg. 200, Ste. 200 / Atlanta, GA 30340
Fax 770-220-3705
Email Release-of-Information@kp.org
For Kaiser Use Only:
1. Print Staff Name: ______________________________
2. Dept: ______________________ Ph#: ____________________
3. Date Received: ____ | ____ | _______
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HEALTH INFORMATION EXCHANGE OPT IN REQUEST FORM

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Completed 12 February 2021

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