NS-11374 (06 -20)
HEALTH INFORMATION EXCHANGE
OPT IN REQUEST FORM
Original: 07/26/2013 Revised: 7/9/2020
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
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.
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
For Kaiser Use Only:
1. Print Staff Name: ______________________________
2. Dept: ______________________ Ph#: ____________________
3. Date Received: ____ | ____ | _______
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