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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 Insur....

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
CA Kaiser NS-9934
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2021 CA Kaiser NS-9934
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