This authorizes the following Kaiser Permanente
Medical Center(s): __________________________
__________________________________________
Patient Name: _____________________________
Kaiser # _______________ Date of Birth: ________
Address: __________________________________
City: _____________________________________
State: __________________ Zip Code: _________
Telephone Number: _________________________
Email: ____________________________________
Note: Fees may apply to certain requests
AUTHORIZATION FOR USE OR DISCLOSURE
OF PATIENT HEALTH INFORMATION
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
Kaiser Foundation Hospitals
Permanente Medical Groups
NS-9934 (2-11) HIPAA COMPLIANT SPANISH-NS-1614; CHINESE-NS-6274
90258 (REV. 2-11) SPANISH 01782-000; CHINESE 01782-002
Kaiser Permanente will not condition treatment, payment, enrollment or
eligibility for benefits on providing, or refusing to provide this authorization.
To: q Produce a copy of medical records as
speciedbelow
q Complete form(s) (Please specify form
type(s)inthePURPOSEsectionbelow)
qAllownamedKPphysiciantoviewrecords
PURPOSE:Thehealthinformationdisclosedmayonlybeusedforthefollowingpurposes:
FOR COPIES, SPECIFY THE HEALTH INFORMATION NEEDED FOR USE OR DISCLOSURE
q
MedicalOfceRecordsdatedfrom__________to__________
qHospital Records dated from __________ to __________
NOTE: Hospital and medical ofce records may include information related to mental health,
alcohol/drug, and HIV references. The actual treatment records from mental health and/or alcohol/drug
departments, and/or results of HIV tests will not be disclosed unless specically requested below.
SIGNATURES AND DATES REQUIRED IF ANY OF THE FOLLOWING BOXES ARE CHECKED
q
Mental Health dated from
________ to _________
Signature:
______________________ Date:________
q
Alcohol/Drugdatedfrom
________ to _________
Signature:
______________________ Date:________
q
HIV Test Results dated from
________ to ________
Signature:
______________________ Date:________
q
SpecicInjury/Treatment:________________Department:_______________datedfrom________to________
q
X-Ray:
q
Imagesand/orFilms
q
Reports Describe:
________________________________________
q
Laboratory Results dated from ____________ to ____________
q
Other (specify):_______________________________________________________________________________
q
ProtectedMinorRecords(AdolescentCondential).Onlyapplicableforpatientrequesters12-17yearsold.
DURATION:
Thisauthorizationshallremainineffectforoneyearfromthedateofsignatureunlessa
differentdateisspeciedhere_______________(date).
REVOCATION:
Youoryourrepresentativecanrevokethisauthorizationuponwrittenrequest.Ifyou
revoke,itwillnotaffectinformationdisclosedbeforethereceiptofthewrittenrequest.
REDISCLOSURE:
Oncethishealthinformationisdisclosed,howtherecipientfurtherdisclosesitmayno
longerbeprotectedunderfederalprivacylaw(HIPAA).
Acopyofthisauthorizationisasvalidasanoriginal.Ihavetherighttoreceiveacopyofthisauthorization.
( )
Media Preference: qPaper qCD(ifavailableelectronically)Delivery Preference: qMail qPickupqFaxqEmail
Date Signature Ifnotpatient,printyournameandrelationship
Kaiser Permanente may disclose this information to:
Recipient Name: ___________________________
Address: _________________________________
City: _____________________________________
State: __________________ Zip Code: _________
Telephone number: _________________________
Faxnumber:_______________________________
Email: ____________________________________
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