Get Ca Kaiser Permanente 90258 2009-2025

Filling out the CA Kaiser Permanente 90258 form online requires careful attention to detail. This guide provides step-by-step instructions to help you navigate the form effectively and ensure all required information is accurately submitted.

Follow the steps to complete the CA Kaiser Permanente 90258 form online.

1. Click ‘Get Form’ button to obtain the form and open it in your web browser.
2. Begin by entering the member or patient’s medical record number in the designated field. This identifier is crucial for ensuring that the requested information is associated with the correct individual.
3. Fill in the name of the individual whose health information is being authorized. Ensure you also list any other names they may have used to avoid identification issues.
4. Provide the address, date of birth, and telephone number of the member or patient to facilitate accurate communication and identification.
5. In the section labeled 'disclose to:', enter the name of the disclosing party and the recipient of the health information, along with their respective addresses and cities.
6. Indicate the duration for which this authorization is effective by entering a specific date, if necessary, or acknowledging that it will remain valid for one year from the signature date.
7. Review the types of information to be disclosed. Check the appropriate boxes corresponding to medical information, psychiatric information, drug/alcohol information, results of an HIV test, or genetic records. Be sure to initial each selected type.
8. Sign and date the form in the designated areas to validate your authorization.
9. If this authorization is signed by someone other than the member or patient, indicate the relationship in the specified area.
10. After completing all sections, ensure all information is accurate. You can then save the changes, download, print, or share the form as needed.

Complete your CA Kaiser Permanente 90258 form online today for efficient management of your health information.