Kaiser Authorization Form
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1
2AUTHORIZATION TO USE AND/OR DISCLOSE PROTECTED HEALTH INFORMATION
1. I authorize Kaiser Foundation Health Plan of Ohio and/or The Ohio Permanente Medical Group, Inc. to
disclose and/or receive for use the following information for the individual named below:
Patient name: ____________________________
Kaiser Medical Record #: ________________________
Address: ________________________________________________________________________________
City/State/ZIP: ___________________________________________________________________________
Phone #: (
) ____________________________
Date of birth: ____________________________
2a. I AUTHORIZE:
2b. TO RELEASE TO:
_______________________________________
_______________________________________
Name of sending person/organization
Name of receiving person/organization
_______________________________________
_______________________________________
Street address
Street address
_______________________________________
_______________________________________
City
State
ZIP code
City
State
ZIP code
3. At my request, the following information may be disclosed and/or used: (specify dates where appropriate)
Immunizations
Date(s):___________
Laboratory results
Date(s):______________
Medical record
Date(s):___________
HIV/AIDS test results
Date(s):______________
Medical record (last two years)
Mental health record
Date(s):______________
X-ray reports
Date(s):___________
Billing record
Date(s):______________
X-ray films
Date(s):___________
Other records
Date(s):______________
(specify type) ____________________________
(specify type) ______________________________
For the purpose of: (check all that apply)
Continuity of care
Personal use
Consultation
Insurance claim
Form completion
Attorney inquiry
Social Security
Workers’ comp
Eligibility/enrollment
Rate setting
Employer request
Appeals
Other (specify) __________________________
Page 1 of 2
Signature and date must be on Page 2 for this authorization to be valid.
Revised 5/16/03; 1/01/04
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