Get Authorization For Kaiser Permanente To Use/disclose Protected ... - Info Kaiserpermanente

Filling out the Authorization For Kaiser Permanente To Use/Disclose Protected Health Information form can feel daunting but is essential for ensuring your healthcare information is shared appropriately. This guide provides a clear, step-by-step approach to assist you in completing the form online.

Follow the steps to correctly fill out your authorization form.

1. Press the ‘Get Form’ button to access and open the form in your chosen editor.
2. Complete the patient section. Enter your full name, any nickname or maiden name, health record number, date of birth, phone number, and home address including city, state, and ZIP code.
3. Specify the purpose for the release of your information in the available section. Use examples like treatment facilitation, billing, or personal understanding.
4. Provide the name of the person or organization that will receive the information. Include their title, phone number, and complete address.
5. Select the purpose for the information exchange by checking the relevant boxes such as 'Facilitate treatment' or 'Summarize treatment'.
6. Indicate the type of information you wish to disclose, specifying if you want all records, X-ray films, or other specific documents. If choosing 'Other', provide a detailed description.
7. Select the preferred media type (electronic or paper) and your delivery method (email, postal mail, or pickup).
8. If you need to disclose sensitive information, initial the corresponding boxes to acknowledge your consent.
9. Carefully read the authorization statement to understand your rights and the limits of the authorization.
10. Sign the form, indicating your relationship to the patient if you are not the patient themselves, and date the authorization.
11. Once completed, ensure all fields are accurately filled. Save changes, and choose to download, print, or share the completed form as needed.

Start completing your authorization form online today to ensure your healthcare information is shared securely.