NS-11379 (06-20)
Colorado 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 Colorado Region (KPCO) 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:
Kaiser Permanente / Data Integrity Group / 11000 East 45th Ave / Denver, CO 80239-3004
For Kaiser Use Only:
1. Print Staff Name: ______________________________
2. Dept: ______________________ Ph#: ____________________
3. Date Received: ____ | ____ | _______
click to sign
signature
click to edit
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