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Get Kaiser Permanente 05022-005 2012-2024

I understand that the medical information released may include any and all information concerning treatment of medical history mental illness alcohol/drug abuse and HIV/AIDS information. provider to provider is generally considered a professional courtesy a health care provider may charge me a fee for disclosure of this health information. content ultimately becomes part of the patient s Kaiser Permanente medical record. MR Name Kaiser Foundation Hospitals The Permanente Medical Group Inc. AUTHORIZATION TO DISCLOSE health INFORMATION TO KAISER PERMANENTE I hereby authorize IMPRINT AREA to disclose to Kaiser Permanente at Provider or Clinic Street Address Name of Provider City State ZIP Location Records and information pertaining to Patient Name Date of Birth Daytime Phone Medical Record Number The type and amount of information to be disclosed is as follows specify dates where appropriate Most recent 2 years of record for adult patients Pediatric Record for minor patients Immunization Record Radiology Reports from date to Radiology Images exam/date All Breast Images and Breast Imaging Reports Laboratory Results from date Other records not listed specify 1. PURPOSE The health information disclosed will be used for continuing care/treatment purposes. DURATION This authorization shall remain in effect for one year rom the date of signature unless a f. different date is specified here date revocation You or your representative can revoke this authorization upon written request. If you revoke it will not affect information disclosed before the receipt of the written request. REDISCLOSURE nce this health information is disclosed how the recipient further discloses it O may no longer be protected under federal privacy law HIPAA. California recipients are required to obtain your authorization before further disclosing this information* A copy of this authorization is as valid as the original* I have a right to a copy of this authorization* Signature of Patient or Personal Representative 05022-005 6-12 FOR CHINESE USE -001 SPANISH -002 Date Personal Representative s Name Print and Relationship DISTRIBUTION WHITE CHART CANARY MEMBER/PATIENT. PURPOSE The health information disclosed will be used for continuing care/treatment purposes. DURATION This authorization shall remain in effect for one year rom the date of signature unless a f. different date is specified here date revocation You or your representative can revoke this authorization upon written request. different date is specified here date revocation You or your representative can revoke this authorization upon written request. If you revoke it will not affect information disclosed before the receipt of the written request. REDISCLOSURE nce this health information is disclosed how the recipient further discloses it O may no longer be protected under federal privacy law HIPAA. If you revoke it will not affect information disclosed before the receipt of the written request. REDISCLOSURE nce this health information is disclosed how the recipient further discloses it O may no longer be protected under federal privacy law HIPAA. California recipients are required to obtain your authorization before further disclosing this information* A copy of this authorization is as valid as the original* I have a right to a copy of this authorization* Signature of Patient or Personal Representative 05022-005 6-12 FOR CHINESE USE -001 SPANISH -002 Date Personal Representative s Name Print and Relationship DISTRIBUTION WHITE CHART CANARY MEMBER/PATIENT. .

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