Get Kaiser Permanente Release Of Information Form Ns 9934 10 03

Filling out the Kaiser Permanente Release Of Information Form Ns 9934 10 03 online is a straightforward process that allows you to authorize the disclosure of your protected health information. This guide provides clear, step-by-step instructions to help you complete the form accurately.

Follow the steps to complete the online form with ease.

1. Click ‘Get Form’ button to access the online version of the Kaiser Permanente Release Of Information Form Ns 9934 10 03.
2. Enter your nickname, maiden name, or any other names you have used in the designated field. This helps ensure that all records are correctly identified.
3. Provide your Social Security number in the specified section. This number helps establish your identity.
4. Fill in your health record number if you have one. This number is used for internal tracking of your health information.
5. Enter your date of birth using the format (MM/DD/YYYY). This assists in verifying your identity.
6. Complete the contact information section including your phone number, address, city, state, and ZIP code.
7. Specify the purpose for the information release in the provided space. Be clear and concise.
8. Indicate the specific information you want disclosed by checking the appropriate boxes. You can choose all records, x-ray films, or other specific information.
9. Provide the details of the person or entity to whom the information should be sent, including their name, title, phone number, and street address.
10. If applicable, initial next to the types of sensitive information to confirm your consent for disclosure.
11. Read the statements regarding the revocation of authorization and the implications of signing the form.
12. Sign and date the form, or have a personal representative sign, if applicable. Provide a description of the representative’s authority if needed.
13. Review the entire form for accuracy. Ensure that all sections are filled correctly.
14. Once satisfied with the completed form, save your changes, and download, print, or share the document as needed.

Start completing your Kaiser Permanente Release Of Information Form online today!