Get Kaiser Permanente Permission To Enroll Form 2020-2025

Filling out the Kaiser Permanente Permission To Enroll Form online is a straightforward process designed to help users authorize the release of medical information. This guide provides clear steps to assist you in completing the form accurately and efficiently.

Follow the steps to fill out the Kaiser Permanente Permission To Enroll Form online.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Fill in the 'release to' section with the name and address of the receiving person or organization. Ensure all fields, including the street address, city, state, and telephone number, are completed accurately.
3. In the 'information to be released' section, check all relevant boxes for the information you wish to authorize for release. You may select an attached form, immunization record, or the copy of medical records from the last two years.
4. Complete the 'special authorization' section by checking any applicable items. If you authorize the release of sensitive information, ensure you sign below.
5. Fill in the date range for the records you want released in the 'release records dating from' section, formatted as MM/DD/YYYY.
6. Indicate the purpose or need for disclosure by checking all relevant boxes. Select from options such as continued medical care, insurance claim, and legal requirements.
7. If applicable, review the specific authorization validity information for your state. This may vary by location, particularly between Maryland, Virginia, and the District of Columbia.
8. Acknowledge your rights regarding this authorization, including the ability to revoke it and receive a copy upon request. Sign the form where indicated.
9. Once all sections are filled out, review the entire form for accuracy, then save any changes made. You can also download, print, or share the completed form as needed.

Complete your Kaiser Permanente Permission To Enroll Form online today to ensure your medical information is released as needed.