_________
( )
(*Kaiser Permanente entities and the instructions for completing this
request are listed on reverse side of this form)
REQUEST OF PATIENT
HEALTH INFORMATION
Note: Fees may apply to certain requests
Patient Name:
Medical Record number:
________________
Birth Date:
_________________________________________
Address:
_____________
City:
_______________________________ State:
_____________
Zip Code:
____________
Phone #: __________________________
( )
Email:
___________________________________
I hereby authorize Kaiser Permanente to disclose this information to:
Check if same as above
Recipient Name:
_______________________________________________________________________
Address:
________________________________
City:
______________
State:
______
Zip Code:
________
( )
Phone #
________________________________
Fax:
Email:
This disclosure can be used for the following purpose(s):
Personal Use Legal Insurance
Medical Treatment
Medical Condition Verication
Disability
FMLA
Workers’ Comp
Check ONLY one of the following three options to identify the health information to be released.
Option 1: Form Completion (a substitute form or relevant medical records may be released)
Option 2: Last 2 years of Kaiser Permanente Medical Ofce and Kaiser Foundation Hospital records
Option 3: Records as specied. 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:
KP Medical Ofce Kaiser Foundation Hospital Immunization
Lab Results
Diagnostic Images Copays & Deductibles Itemized Billing
Pharmacy
Other (provider, department, specialty):
_________________________________________
NOTE: Hospital and Medical Office records released as part of this request may contain references
related to mental health, addiction, and HIV medical conditions.
Check the boxes below if you want this release to include the following information, Otherwise,
this information will be excluded.
Mental Health Treatment Records
Addiction Medicine Treatment Records
HIV Test Results
Media Type: Electronic Paper Delivery Preference: Electronic Mail Fax
Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benefits on whether you sign
this
request. This disclosure is made at your request. For Virginia patients, a copy of this request, and a note
stating to whom your information was disclosed will be included in your medical record. A copy of the original
request is valid. You have a right to a copy of this completed request.
Date Signature If personal representative, print name/relationship
NS-9934 (2-16) SPANISH-NS-1614; CHINESE-NS-6274
NCAL: 90258 (REV. 2-16) SPANISH 01782-000; CHINESE 01782-002
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
_________________________________
_____________
Instructions:
1. Complete the patient identification information at the top
2. Complete all required information for the recipient including a valid email address or fax number
3. Check the box for purpose of disclosure
4. Check the box(es) for the type of information to be disclosed
5. If selecting Option 3, you must complete Steps 1 & 2
6. Date and Sign the written request form
7. If you are a personal representative, print your name and relationship
8. Submit written request to [email protected] or fax 770-220-3705
9. Keep a copy for your record
Please complete the patient questionnaire if requesting FMLA, Disability or Obstetrics
Please allow up to 10 business days to process this request
“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.
