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Get CA Kaiser NS-9934 2016

A copy of the original authorization is valid. You have a right to a copy of this completed authorization. Date Signature NS-9934 9-15 SPANISH-NS-1614 CHINESE-NS-6274 NCAL 90258 REV. 9-15 SPANISH 01782-000 CHINESE 01782-002 If personal representative print name/relationship ORIGINAL - DISCLOSING PARTY CANARY - PATIENT plan and your doctors a Permanente medical or dental group. It also includes different groups depending on where you live. All states where we do business Kaiser Foundation Hospitals California The Permanente Medical Group Southern California Permanente Medical Group Colorado Colorado Permanente Medical Group P. Patient Name Medical Record number Birth Date Kaiser Permanente entities are listed on reverse side of this form Address AUTHORIZATION FOR USE City State OR DISCLOSURE OF PATIENT Zip Code Phone HEALTH INFORMATION Email Note Fees may apply to certain requests Recipient Name Phone This disclosure can be used for the following purpose s q Personal Use q Legal q Insurance q Medical Treatment q Medical Condition Verification q Disability q FMLA q Workers Comp Check ONLY one of the following three options to identify the health information to be released. q Option 1 Form Completion a substitute form or relevant medical records may be released q Option 2 Last 2 years of Kaiser Permanente Medical Office and Kaiser Foundation Hospital records q Option 3 Records as specified. You must complete Step 1 and Step 2 below. Step 1. Enter date range or date s of the records to be released Step 2. Select types of records to be released KP Medical Office q Kaiser Foundation Hospital q Immunization q Lab Results q Diagnostic Images q Copays Deductibles Itemized Billing q Pharmacy q Other provider department specialty NOTE Hospital and Medical Office records released as part of this authorization may contain references related to mental health addiction and HIV medical conditions. Check the boxes below if you want this release to include the following information Otherwise this information will be excluded* Mental Health Treatment Records q Addiction Medicine Treatment Records q HIV Test Results Media Type q Electronic q Paper Delivery Preference q Electronic q Mail q Pickup DURATION Authorization shall remain in effect for one year from the date of signature below. However in Washington D*C* permission to release addiction medicine treatment records expires after six 6 months. 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 on the reverse side of this form* 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. 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.

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