Get Kaiser Permanente 0002-1966 2010-2025

Filling out the Kaiser Permanente 0002-1966 authorization form online is a straightforward process. This guide will provide you with comprehensive, step-by-step instructions to ensure that you fill out the form accurately and efficiently.

Follow the steps to fill out the form seamlessly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the name of the member or patient in the designated field, including any other names they may have used.
3. Fill in the date of birth using the format MM/DD/YYYY.
4. Provide the medical record number or group number as applicable.
5. Complete the daytime phone number field to ensure easy communication.
6. Fill in the street address, city, state, and zip code of the member or patient.
7. Indicate the records and information you wish to disclose by checking the appropriate sections or filling in requested specifics.
8. Specify the recipient's name and mailing address. If applicable, provide a fax number for direct transmission.
9. Detail the duration for which this authorization will remain in effect; default to one year unless you specify differently.
10. Select the purpose for the requested use or disclosure of health information from the available options.
11. Sign and date the form, indicating your relationship if you are signing on behalf of another individual.
12. Once completed, save your changes, and you may choose to download, print, or share the form as needed.

Start completing your Kaiser Permanente 0002-1966 form online today!