Final Disc

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This disclosure can be used for the following purpose(s): q Personal Use q Legal q Insurance q Medical Treatment q Medical Condition Verification q Disability q FMLA q Workers’ Comp

Kaiser Permanente may release this information to: q Check if same as above Recipient Name: _______________________________________________________________________ Address: ________________________________ City: ______________ State:______ Zip Code: ________ Phone # ________________________________ Email: ________________________________________

Media Type: q Electronic q Paper Delivery Preference: q Electronic q Mail q Pickup

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

(*Kaiser Permanente entities are listed on reverse side of this form)

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ORIGINAL - DISCLOSING PARTY CANARY - PATIENT NS-9934 (2-16) SPANISH-NS-1614; CHINESE-NS-6274 NCAL: 90258 (REV. 2-16) SPANISH 01782-000; CHINESE 01782-002

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 benefits 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.

Date Signature If personal representative, print name/relationship

NOTE: Hospital and Medical Office records released as part of this authorization may contain references related to mental health, addiction, and HIV medical conditions.

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q KP Medical Office 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): _________________________________________

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 Office and Kaiser Foundation Hospital records q Option 3: Records as specified. 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:

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

“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.

1. Patient Name:
2. Medical Record number:
3. Birth Date:
4. Address:
5. City:
6. State:
7. Zip Code:
8. Email:
9. Recipient Name:
10. Address_2:
11. City_2:
12. State_2:
13. Zip Code_2:
14. Email_2:
15. Step 1 Enter date range or dates of the records to be released:
16. Other provider department specialty:
17. Date:
18. If personal representative print namerelationship:
19. Phone #:
20. AreaC_2:
21. Phone #_2:
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33. AreaCode:
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