Fillable USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION AUTHORIZATION (Kaiser Permanente)

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USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION AUTHORIZATION (Kaiser Permanente)

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(*Kaiser Permanente regions are
listed on reverse side of this form)
AUTHORIZATION FOR
USE OR DISCLOSURE
OF PATIENT HEALTH
INFORMATION
Note: Fees may apply to certain requests
See reverse side for instructions to fill out this form.
Failure to follow instructions may result in processing delay.
1. PATIENT
INFORMATION
PRINT Patient Name:
Birth Date (mm/dd/yyyy):
Medical Record Number:
Address:
City: ____________________________ State: Zip:
Phone #: (_____)
Email:
2. KAISER PERMANENTE MAY RELEASE THIS INFORMATION TO: Check if the same as 1 above
Organization or person
:
Address:
City: ______________________________________________ State: ____________ Zip:
Phone:
(_____)
_________________________________ Fax
(_____)
Email:
DELIVERY MET
HOD FOR RECORDS
:
Secure
Email
Fax Paper/Mail (may take longer to process)
Doctor
Legal Insurance Medical Leave Personal / Other
3. PURPOSE OF RELEASE:
Medical records
Billing records
Immunizations
Radiology reports:
Pharmacy records
Radiology images (on CD):
Other: (provider, department, specialty):
5. PATIENT AUTHORIZATION: I understand that:
Information released may include information regarding the testing, diagnosis or treatment of HIV/AIDS, sexually
transmitted diseases, chemical dependency or mental health and for patients ages 13-17, information regarding
reproductive care. I give my specific authorization for this information to be released.
Generally, Kaiser Foundation Health Plan of Washington and any other entity covered by the Health Insurance
Portability and Accountability Act of 1996, may not condition treatment, payment, enrollment, or eligibility for benefits
on whether I sign this authorization. If this authorization is for purposes of determining enrollment, eligibility,
underwriting or risk rating prior to enrollment, not signing or revoking this authorization may impact enrollment or
benefit determinations by Kaiser Foundation Health Plan of Washington.
I may revoke this authorization in writing. If I revoke my authorization, it will not affect any actions already taken
based upon this authorization.
Once disclosed, health care information may be subject to redisclosure by the recipient and may no longer be
protected under health information privacy laws.
6. SIGNATURE: ___________________________________________________ DATE: ________________
If personal representative*, print name and relationship:
*Documentation may be required
to prove authority to sign on behalf of the patient.
7. MINOR SIGNATURE: _____________________________________________ DATE: ________________
Signature of minor ages 13-17 is required for certain information, see number 7 on instruction page)
8.
This authorization expires 90 days from the date signed OR on the date or event indicated here:
Business Of
fice/Clinic Staff: Has this request been processed?
WWA YES, already processed: send to Scanning at RCS
WWA NO, needs processing: fax to ROI at 206-630-6849
EWA YES, already processed: send to Scanning at ACN-AC3
EWA NO, needs processing: fax to ROI at 509-232-3127
DL1056470-01-20 HIM
4. INFORMATION FROM (DATE) _____/ /_____ TO (DATE) ____/_____/_______ TO BE RELEASED:
Please visit kp.org for contact information for the following Kaiser Permanente regions:
•
California
•
Colorado
•
Georgia
•
Hawaii
•
Mid-Atlantic States (Maryland, Virginia & Washington DC)
•
Northwest (Oregon, Longview & Vancouver, Washington)
•
Washington
INSTRUCTIONS:
1. PATIENT INFORMATION: Print name of patient, birth date, medical record number (if known), address, phone
number and email.
2.
RECIPIENT INFORMATION:
Print name, address, phone number, fax number and email address.
Delivery method: Electronic delivery is recommended. Please PRINT the email address clearly.
3.
PURPOSE:
Check the box that applies to the reason the records are being requested.
4.
INFORMATION TO BE RELEASED:
•
Medical records – a maximum of 10 years of records
•
Billing records – premium payments not included
•
Radiology images – please specify images and/or dates needed
5.
Read the
PATIENT AUTHORIZATION section.
6.
SIGNATURE:
Sign and date. Personal representative should print name and indicate relationship to the patient.
Documentation may be required to prove authority to sign on behalf of the patient.
7.
MINOR SIGNATURE:
Minor patients ages 13 to 17 must authorize the release of information related to
HIV/AIDS,
sexually transmitted diseases, chemical dependency, mental health and reproductive care.
8.
EXPIRATION:
If no date or event is given, authorization will expire 90 days from date signed.
To submit your request, please fax your completed form to the appropriate locations listed below. Fax
submission is preferred; you may also send by mail or email. Please visit our website
www.kp.org/wa
for
additional copies of this form or for more information.
Kaiser Foundation Health Plan of Washington
Release of Information
MAILSTOP: RCG-D1N-02
PO Box 9812
Renton, WA 98057-9054
Phone: 206-630-6848 or toll-free 1-866-656-4184
Hours: 8 a.m. to 5 p.m.
Email: KPWA-ROI@kp.org
Fax: 206-630-6849
Eastern Washington
Kaiser Foundation Health Plan of Washington
Health Information Management
MAILSTOP: ACN-AC3
PO Box 204
Spokane, WA 99210-9809
Phone: 509-241-7824
Hours: 8 a.m. to 5 p.m.
Email: KPWA-ROI@kp.org
Fax: 509-232-3127
To request Radiology Images ONLY (x-rays, MRI’s, CT’s, mammograms etc.), please send requests to:
Kaiser Foundation Health Plan of Washington
Central Imaging Center
201 16th Ave E
Seattle, WA 98112
Phone: 206-326-3715
Fax: 206-326-2007
2021-XB-7_ACA_Notice_Taglines
Notice of Nondiscrimination
Kaiser Foundation Health Plan of Washington and Kaiser Foundation Health Plan of Washington Options, Inc.
(“Kaiser Permanente”) comply with applicable Federal and Washington state civil rights laws and do not
discriminate, exclude people, or treat them differently on the basis of race, color, national origin, age,
disability, sex, sexual orientation, gender identity, or any other basis protected by applicable federal,
state, or local law. We also:
• Provide free aids and services to people with disabilities to communicate effectively with us,
such as:
– Qualified sign language interpreters
– Written information in other formats (large print, audio, accessible electronic formats, and
other formats)
– Assistive devices (magnifiers, Pocket Talkers, and other aids)
• Provide free language services to people whose primary language is not English, such as:
– Qualified interpreters
– Information written in other languages
If you need these services, contact Member Services at 1-888-901-4636 (TTY 711).
If you believe that Kaiser Permanente has failed to provide these services or discriminated in another
way on the basis of race, color, national origin, age, disability, sex, sexual orientation, or gender identity,
you can file a grievance with our Civil Rights Coordinator by writing to P.O. Box 35191, Mail Stop:
RCR-A3S-03, Seattle, WA 98124-5191 or calling Member Services at the number listed above. You can file
a grievance by mail, phone, or online at kp.org/wa/feedback. If you need help filing a grievance, our Civil
Rights Coordinator is available to help you.
You can also file a civil rights complaint with:
• The U.S. Department of Health and Human Services, Office for Civil Rights electronically through
the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health
and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC
20201, 1-800-368-1019, 800-537-7697 (TDD)
Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
• The Washington State Office of the Insurance Commissioner, electronically through the
Office of the Insurance Commissioner Complaint portal available at
https://www.insurance.wa.gov/file-complaint-or-check-your-complaint-status, or by phone at
800-562-6900, 360-586-0241 (TDD). Complaint forms are available at
https://fortress.wa.gov/oic/onlineservices/cc/pub/complaintinformation.aspx
XB0001444-57-21
Multi-language Interpreter Services
English: ATTENTION: If you speak a language other than English, language assistance services, free of
charge, are available to you. Call 1-888-901-4636 (TTY 711).
Español (Spanish): ATENCIÓN: si habla otro idioma que no sea español, tiene a su disposición servicios
gratuitos de asistencia en su idioma. Llame al 1-888-901-4636 (TTY 711).
中文 (Chinese)：注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電
1-888-901-4636 (TTY 711)。
Tiếng Việt (Vietnamese): CHÚ Ý: Nếu quý vị nói tiếng Việt, hiện có các dịch vụ hỗ trợ ngôn ngữ miễn phí
dành cho quý vị. Gọi số 1-888-901-4636 (TTY 711).
한국어 (Korean): 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수
있습니다. 1-888-901-4636 (TTY 711) 번으로 전화해 주십시오.
Русский (Russian): ВНИМАНИЕ! Если вы говорите на русском языке, вам доступны
бесплатные услуги перевода. Звоните 1-888-901-4636 (TTY 711).
Tagalog: PAUNAWA: Kung nagsasalita ka ng wika maliban sa Tagalog, maaari kang gumamit ng mga
serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-888-901-4636 (TTY 711).
Українська (Ukrainian): УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до
безкоштовної служби мовної підтримки. Телефонуйте за номером
1-888-901-4636 (TTY 711).
មែរ (Khmer)៖ សូមយកចិ
  
  1-888-901-4636 (TTY 711)
日本語 (Japanese): 注意事項：英語以外の言語を話される場合、無料の言語サポートをご利用
いただけます。1-888-901-4636 (TTY 711) まで、お電話にてご連絡ください。
አማርኛ (Amharic)፥ ማሳሰቢያ፥ የሚናገሩት ቋንቋ አማርኛ ከሆነ የትርጉም እገዛ አገልግሎቶች፣ በነጻ ለእርስዎ
ይቀርባሉ ወደ ሚከተለው ቁጥር ይደውሉ 1-888-901-4636 (መስማት ለተሳናቸው 711)።
Oromiffa (Oromo): XIYYEEFFANNAA: Afaan dubbattu Oroomiffa yoo ta’e, tajaajila gargaarsa afaanii,
kanfaltiidhaan ala, ni argama. 1-888-901-4636 (TTY 711) irraatti bilbilaa.
 (Punjabi):  :     ,         
 1-888-901-4636 (TTY 711)  ਕ ਲ 
 :
:
 (Arabic) ةيبرعلا
1-888-901-4636 TTY 711
Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche
Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-888-901-4636 (TTY 711).
ພາສາລາວ (Lao): ໂປດຊາບ:  

 
  
   . 1-888-901-4636 (TTY 711).
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USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION AUTHORIZATION (Kaiser Permanente)

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Completed 24 November 2021

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