Kaiser Authorization Form (Page 2 of 2) in pdf

Patient name:

Kaiser Medical Record No.:

Date of birth:

4. I understand that the information released upon authority of this authorization may include

information concerning treatment of physical and mental illness, alcohol/drug abuse, HIV/AIDS test

results, diagnoses or treatment of HIV/AIDS, and past medical history information.

5. This authorization will expire 60 days from the date of signing. I understand that I have a right to

revoke this authorization in writing at any time and must submit my written revocation to Kaiser

Permanente, Medical Correspondence, 5410 Lancaster Drive, Brooklyn Heights, Ohio 44131. I

understand that the revocation will not apply to any actions taken in reliance on this authorization.

Revocation of an authorization used to secure a policy of insurance, including health insurance from a

Kaiser Permanente entity, may not be permitted during the period of time the insurer may contest the

policy issued or a claim under the policy.

6. I understand that Kaiser Permanente may not condition treatment, payment, enrollment in the health

plan, or eligibility for benefits on my execution of this authorization, except when Kaiser Permanente

seeks authorization (1) because it is providing research-related treatment; (2) for purposes of

determining health plan eligibility, enrollment underwriting, or risk rating, so long as the

authorization is not for use or disclosure of HIPAA psychotherapy notes; or (3) because it is providing

treatment solely for the purpose of creating protected health information for the disclosure to a third

party.

7. I understand that any disclosure of information carries with it the potential for an unauthorized re-

disclosure by the recipient and is not protected by the Kaiser Permanente policy or the HIPAA

Privacy Rule.

8. Kaiser Foundation Health Plan of Ohio and The Ohio Permanente Medical Group contract with a

copy service authorized to duplicate records and process requests for medical records. I understand

that a reasonable fee may be charged for duplication of records and accept full financial responsibility

for that fee.

9. I understand that I (or person authorized to act as my representative) am entitled to receive a copy of

this authorization.

By signing this form below, you are authorizing the release of the requested information identified above.

If the person signing is not the member/patient, indicate the relationship to the member/patient and attach

supporting authorization or legal documentation.

_______________________________________________

____________________

Signature of patient or authorized personal representative

Date

_______________________________________________

____________________

Authorized personal representative’s name

Relationship to patient

Page 2 of 2

Signature and date must be on Page 2 for this authorization to be valid.

Revised 5/16/03; 1/01/04

Kaiser Authorization Form Page 2