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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How to fill out the CA Kaiser NS-9934 online
Filling out the CA Kaiser NS-9934 online can seem daunting, but with clear guidance, the process can be manageable. This guide will provide step-by-step instructions to help you complete the form with confidence and ease.
Follow the steps to fill out the CA Kaiser NS-9934 online
- Click the ‘Get Form’ button to access and open the CA Kaiser NS-9934 form in your editor of choice.
- Begin by entering the patient name in the designated field at the top of the form.
- Next, fill in the medical record number, birth date, address, city, state, and zip code.
- Provide a phone number and email address in the respective fields to ensure you can be contacted regarding your request.
- Identify the recipient for the information by checking the box if the same as the patient; if not, provide the recipient’s name and contact details including address, phone number, and email.
- Specify the purpose of the disclosure by checking one of the provided options, such as personal use or medical treatment.
- Select one of the three options to identify the health information to be released: option one for form completion, option two for the last two years of records, or option three for specific records where you will need to enter date(s) and types of records.
- If you selected option three, proceed to step one to enter the date range or specific dates of the records required.
- Then, in step two, indicate the types of records to be released by checking the relevant boxes.
- Decide whether to include mental health treatment records, addiction medicine treatment records, or HIV test results by checking the appropriate boxes.
- Select the preferred media type for the information, choosing either electronic or paper.
- Choose how you would like to receive the information by selecting electronic delivery, mail, or pickup.
- Acknowledge the duration of authorization by understanding it remains effective for one year, or six months in Washington, D.C.
- Finally, sign and date the authorization to complete the process. If you are completing this on behalf of someone else, ensure to print your name and relation in the designated area.
Complete your CA Kaiser NS-9934 form online today for a seamless experience.
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