The Kaiser Records Request form is a document designed for Kaiser Permanente patients or their authorized representatives to formally request the use or disclosure of their health information to third parties, which may include legal, insurance, or medical certification purposes. This process is directed through a specific protocol on Kaiser Permanente's website, ensuring patient convenience and confidentiality. For those needing to access or share their health records, simply click the button below to fill out the form.
The Kaiser Records Request Form is a critical document for patients or their authorized representatives seeking to disclose their health information to third-party recipients, which may entail certain fees. It encompasses a comprehensive authorization for the use or disclosure of patient health information to specified parties for distinctive purposes such as legal matters, insurance claims, medical certification, among others. This form notably addresses the inclusion of sensitive information, including mental health, addiction, and HIV medical details, with explicit consent from the patient or their representative. Additionally, the form delineates options for the time frame of records to be disclosed, ranging from the last two months to all electronic records, and specifies the conditions under which certain protected health information, like mental health treatment or genetic testing results, can be included in the disclosure. The authorization's duration extends for six months from the signature date, with provisions for revocation by the patient or their representative to discontinue future releases. It also highlights the implications of redisclosure, which may not be protected under federal privacy law (HIPAA) once the information is released. Moreover, it reassures that Kaiser Permanente does not condition treatment or payment on the signing of this authorization, underscoring the patient’s autonomy in the decision. Lastly, the form prompts the patient to keep a copy for their records and provides guidance on obtaining a copy of this authorization for personal records, ensuring transparency and accessibility in managing personal health information.
Patient Name: __________________________________________
Medical Record Number: _________________________________
Birth Date: ___________ Email: ____________________________
Do not use for patient copies of or access to their medical records. Patients should go to kp.org/requestrecords to conveniently request medical records, FMLA and Disability certifications.
AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION
To the Following Third-Party Recipient (Fees may be required)
Recipient Name: ______________________________________________________________________________
Address: ______________________________________________________________________________________
City: ___________________________________________________ State: ________ Zip Code: ______________
Phone # ( ______ ) __________________ Email: _____________________________________________________
This disclosure can be used for the following purpose(s): Legal Insurance Medical Certification Other
Hospital and Medical Office records released as part of this authorization may contain references related to mental health, addiction, and HIV medical conditions documented by primary care.
I authorize the following to be disclosed for the selected time frame:
Form Completion (a substitute form or relevant medical records may be released in lieu) Medical Records
Diagnostic Images
Itemized Billing Records
Pharmacy Copays
Medical Copays
Time Frame: Last
2 months
6 months
1 year
2 years
5 years
All electronic records
Check the boxes below if you want this release to include the protected treating department or HIV initial test result information. If not checked, this treating department information will be excluded.
Mental Health Treatment Records Addiction Medicine Treatment Records HIV Lab Test Results Kaiser Permanente Oregon locations need to also check this box if they want Genetic Testing information released.
DURATION: Authorization shall remain in effect for 6 months from the date of signature below.
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 found on kp.org/requestrecords. 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.
We will provide the requested information in electronic format to the recipient unless the recipient contact us to make other arrangements.
Date
Signature
If personal representative, print name/relationship
NS-9934 (08-21) SPANISH-NS-1614; CHINESE-NS-6274
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
Instructions:
1)Complete the patient identification information on the top right-hand corner
2)Complete all required information for the recipient including a valid email address
3)Check the box for purpose of disclosure
4)Check the box(es) for the type of information to be disclosed and also check the box for a timeframe
5)If you want specially protected information to be included, check the appropriate box(es)
6)Enter the date you are signing the authorization
7)Sign the form
8)If you are a personal representative, print your name and relationship. We may reach out for you to provide additional documentation if needed.
9)Submit this form to the third party you are authorizing to obtain records
10)Keep a copy for your records
“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.
To find contact information go to kp.org and search locations for your region/market listed below or alternatively go to kp.org/requestrecords and indicate your region/market.
All states where we do business:
•Kaiser Foundation Hospitals
•Kaiser Permanente Insurance Company
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.
Mid-Atlantic (Maryland/Virginia/Washington, D.C.):
•Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
•Mid-Atlantic Permanente Medical Group, P.C.
Washington:
•Kaiser Foundation Health Plan of Washington
•Washington Permanente Medical Group, P.C.
Hawaii:
•Kaiser Foundation Health Plan, Inc., Hawaii Region
•Hawaii Permanente Medical Group, Inc.
•Maui Health Systems
Northwest (Oregon/SW Washington):
•Kaiser Foundation Health Plan of the Northwest
•Northwest Permanente, P.C.
•Permanente Dental Associates, P.C.
California - North:
•Kaiser Foundation Health Plan, Inc., Northern California Region
•The Permanente Medical Group, Inc.
California - South:
•Kaiser Foundation Health Plan, Inc., Southern California Region
•Southern California Permanente Medical Group
Itemized Billing Records Pharmacy Copays Medical Copays
Time Frame: Last
2 months 6 months 1 year 2 years 5 years All electronic records
After completing the Kaiser Records Request form, individuals are authorizing the release of their health information to a specified third party. This may be necessary for a variety of reasons, including legal matters, insurance claims, or medical certifications. It's important to fill out the form carefully to ensure accurate handling and transfer of potentially sensitive information. Following the submission of the form, it is advisable to keep a copy for personal records. Additionally, the information released as described on the form may no longer be protected under federal privacy law (HIPAA), and further disclosures by the recipient may require additional authorizations.
It's important for Kaiser Permanente members and their representatives to accurately complete and submit this form to the correct recipient to facilitate the authorized use or disclosure of patient health information. Should the circumstances change, the authorization can be revoked by submitting a written request to the appropriate Release of Information Unit, ensuring control over one's personal health information.
The Kaiser Records Request form is designed for a patient to authorize Kaiser Permanente to disclose their health information to a third-party recipient. This could be for purposes such as legal, insurance, medical certification, or others. It is not intended for patients seeking copies of their records for personal use. In those cases, patients are directed to use kp.org/requestrecords.
For personal access to medical records or requests for FMLA and Disability certifications, you should visit kp.org/requestrecords. This website provides a convenient way for patients to request their medical records directly.
The form allows for the disclosure of various types of information, including:
In addition, you can opt to include specially protected information such as mental health treatment records, addiction medicine treatment records, HIV lab test results, and, for Oregon locations, genetic testing information.
You can choose the time frame for the records you wish to disclose. Options include the last 2 months, 6 months, 1 year, 2 years, 5 years, or all electronic records.
Yes, either you or your personal representative may cancel this authorization at any time by submitting a written request to the Release of Information Unit for your region, as listed on kp.org/requestrecords. Note that revoking this authorization will not affect any information that was released prior to the receipt of your request.
This authorization remains valid for 6 months from the date it is signed. After this period, a new authorization must be completed if further disclosures are needed.
Once your health information is released, it may no longer be protected by federal privacy law (HIPAA). State or other federal laws might require the recipient to obtain further authorization from you before they can disclose your information to others. Kaiser Permanente will not condition treatment, payment, enrollment, or eligibility for benefits on your decision to sign the authorization.
If you are a personal representative making the request, you should sign the form and print your name and relationship to the patient. Additional documentation confirming your authority to act on behalf of the patient may be required.
The completed form should be submitted to the third-party recipient that you are authorizing to obtain your records. Ensure you keep a copy for your records.
Yes, providing a valid email address for the recipient is crucial to ensure the requested information can be sent electronically, unless the recipient requests a different arrangement.
When filling out the Kaiser Records Request form, people often make several mistakes that can delay or complicate the process of getting the necessary health information. Avoiding these common errors ensures the request is processed smoothly and efficiently.
By paying close attention to these details, individuals can facilitate a smoother process in obtaining the necessary medical information from Kaiser Permanente.
When dealing with healthcare, particularly when requesting records from large organizations like Kaiser Permanente, it’s important to have all the necessary documents ready. Along with the Kaiser Records Request form, there are several other forms and documents you might need to complete the process smoothly. Here’s a list of documents commonly used in conjunction with the Kaiser Records Request form:
Understanding the purpose of these documents and having them prepared ahead of time can significantly streamline the process of requesting and transferring medical records or receiving care. Remember, the specifics of each document might vary by state and the healthcare provider, so it's wise to check with Kaiser Permanente or your healthcare provider directly for the most accurate information. Keeping a personal copy of all submitted forms for your records is also a good practice.
HIPAA Authorization Form for Release of Information: Similar to the Kaiser Records Request form, the HIPAA Authorization Form is utilized to authorize the release of a patient's health information to a third party. Both documents are essential for ensuring that the disclosure of sensitive medical information complies with the Health Insurance Portability and Accountability Act (HIPAA), focusing on protecting the patient's privacy. Like the Kaiser form, it specifies the nature of the information to be disclosed, the purpose of the disclosure, and the duration of the authorization.
Medical Power of Attorney (Healthcare Proxy): This legal document allows an individual to appoint someone else to make medical decisions on their behalf if they become unable to do so. Although it serves a different primary purpose from the Kaiser Records Request form, both involve elements of medical decision-making authority and patient consent, particularly when the Kaiser form is signed by a personal representative who might also hold a Medical Power of Attorney.
Request for Access to Protected Health Information: This request form is used by patients to access their health records directly from medical providers. It shares similarities with the Kaiser Records Request form in function and purpose but is specifically geared toward patient access rather than third-party disclosures. Both forms facilitate the provision of health information, albeit for slightly different purposes and recipients, and emphasize following HIPAA guidelines.
Disability Benefits Forms: These forms are used to apply for disability benefits and require medical information as part of the application process. They are similar to the Kaiser Records Request form in that they might require specific medical records or certifications concerning the individual's health condition. While the Kaiser form can specifically request this information for purposes such as disability certification, both types of documents are instrumental in accessing benefits that depend on medical documentation.
Life Insurance Application: Throughout the application process for life insurance, individuals may need to authorize the release of their medical records to the insurance company. This process mirrors the mechanism of the Kaiser Records Request form, where individuals specify the nature of information to be disclosed for insurance purposes. Both forms ensure that sensitive health information is shared securely and with explicit consent for insurance-related evaluations.
Consent Form for Research Studies: Like the Kaiser Records Request form, consent forms for participation in medical research studies often require detailed health information disclosure clauses. These consent forms are critical for ensuring that participants are aware of the type of health information being accessed and used for research, emphasizing voluntary participation and informed consent, akin to the patient authorization necessary for the Kaiser form.
When filling out the Kaiser Records Request form, it's important to follow a set of guidelines to ensure the process is smooth and effective. Here are a list of things you should and shouldn't do:
Misconceptions about the Kaiser Records Request form can lead to confusion and a delay in obtaining necessary information. Understanding the form helps in making the process smoother for patients and their families. Here are seven common misconceptions and their clarifications:
Addressing these misconceptions clarifies the specific uses and limitations of the Kaiser Records Request form, helping patients and third parties navigate the process of information disclosure more effectively.
When navigating the complexities of the Kaiser Records Request form, understanding its key components is crucial for ensuring that your request for medical records is processed smoothly and efficiently. Below are six vital takeaways that can guide patients and their representatives through this process.
Accurately completing the Kaiser Records Request form requires attention to detail and a clear understanding of one’s rights and the implications of sharing personal health information. By considering these key takeaways, patients can navigate the process more confidently, ensuring that their health records are used appropriately and that their privacy is respected.
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