Patient Name:
_________________________________________
Medical Record number:
________________
Birth Date:
_________
Address:
______________________________________________
City:
_______________________________ State: _____________
Zip Code:
____________
Phone #: __________________________
Email:
________________________________________________
Note: Fees may apply to certain requests
AUTHORIZATION FOR USE
OR DISCLOSURE OF PATIENT
HEALTH INFORMATION
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
(*Kaiser Permanente entities are
listed on reverse side of this form)
NS-9934 (9-15) SPANISH-NS-1614; CHINESE-NS-6274
NCAL: 90258 (REV. 9-15) SPANISH 01782-000; CHINESE 01782-002
NOTE: Hospital and Medical Ofce records released as part of this authorization may contain references
related to mental health, addiction, and HIV medical conditions.
DURATION: Authorization shall remain in effect for one year from the date of signature below. However, in
Washington, D.C. permission to release addiction medicine treatment records expires after six (6) months.
REVOCATION: You or your personal representative may cancel this authorization for future releases by submitting
a written request to the Release of Information Unit listed for your region of service on the reverse side of this form.
Your cancellation will not affect information that was released prior to receipt of the written request.
REDISCLOSURE: Once this information is released, it may not be protected under federal privacy law (HIPAA).
State or other federal law may require the recipient to obtain your authorization before further disclosure.
Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benets on whether you sign
this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization, and a
note stating to whom your information was disclosed will be included in your medical record. A copy of the original
authorization is valid. You have a right to a copy of this completed authorization.
( )
Media Type: q Electronic q Paper Delivery Preference: q Electronic q Mail q Pickup
Date Signature If personal representative, print name/relationship
( )
Check the boxes below if you want this release to include the following information, Otherwise,
this information will be excluded.
q
Mental Health Treatment Records qAddiction Medicine Treatment Records qHIV Test Results
qKP Medical Ofce q Kaiser Foundation Hospital qImmunization q Lab Results
q Diagnostic Images q Copays & Deductibles qItemized Billing q Pharmacy
q Other (provider, department, specialty): _________________________________________
Kaiser Permanente may release this information to:
q
Check if same as above
Recipient Name:
_______________________________________________________________________
Address:
________________________________
City:
______________
State:
______
Zip Code:
________
Phone #
________________________________
Email:
________________________________________
This disclosure can be used for the following purpose(s):
q
Personal Use q Legal q Insurance
q
Medical Treatment q Medical Condition Verication q Disability q FMLA q Workers’ Comp
Check ONLY one of the following three options to identify the health information to be released.
qOption 1:
Form Completion (a substitute form or relevant medical records may be released)
q Option 2: Last 2 years of Kaiser Permanente Medical Ofce and Kaiser Foundation Hospital records
q Option 3: Records as specied. You must complete Step 1 and Step 2 below.
Step 1. Enter date range or date(s) of the records to be released: _____________________________
Step 2. Select types of records to be released:
“Kaiser Permanente” means both your insurance company (a Kaiser Permanente health
plan) and your doctors (a Permanente medical or dental group). It also
includes different groups depending on where you live.
All states where we do business:
• Kaiser Foundation Hospitals
California:
• Kaiser Foundation Health Plan, Inc., Northern California Region
• The Permanente Medical Group
• Kaiser Foundation Health Plan, Inc., Southern California Region
• Southern California Permanente Medical Group
Colorado:
• Kaiser Foundation Health Plan of Colorado
• Colorado Permanente Medical Group, P.C.
Georgia:
• Kaiser Foundation Health Plan of Georgia, Inc.
• The Southeast Permanente Medical Group, Inc.
Hawaii:
• Kaiser Foundation Health Plan, Inc., Hawaii Region
• Hawaii Permanente Medical Group, Inc.
Mid-Atlantic States:
• Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
• Mid-Atlantic Permanente Medical Group, P.C.
Northwest:
• Kaiser Foundation Health Plan of the Northwest
• Northwest Permanente, P.C.
• Permanente Dental Associates, P.C.