Contents
The Kaiser Records Request form serves as a crucial tool for individuals seeking to authorize the release of their medical information to a designated third party. This form requires essential patient identification details, including the patient's name, medical record number, birth date, and email address. It is important to note that this form is not intended for patients to access their own medical records; instead, they should visit kp.org/requestrecords for such requests. The form includes an authorization section where patients can specify the recipient's name and address, along with the purpose for the disclosure, such as legal, insurance, or medical certification. Patients can select various types of records to be disclosed, including medical records, diagnostic images, and billing records, and they can also indicate a specific time frame for the requested information. Additionally, the form addresses the inclusion of sensitive information, such as mental health treatment records and HIV lab test results, which requires explicit consent. The authorization remains valid for six months, and patients have the right to revoke it at any time by submitting a written request. Lastly, the form highlights the potential risks associated with redisclosure of the released information, emphasizing the importance of understanding privacy protections under federal and state laws.
Preview - Kaiser Records Request Form
Patient Name:
__________________________________________
Medical Record Number:
_________________________________
Birth Date:
___________
Email:
____________________________
Do not use for patient copies of or access to their medical records. Patients should go to kp.org/requestrecords
to conveniently request medical records, FMLA and Disability certifications.
AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION
To the Following Third-Party Recipient (Fees may be required)
Recipient Name:
______________________________________________________________________________
Address: ______________________________________________________________________________________
City:
___________________________________________________
State:
________
Zip Code:
______________
Phone # (
______
)
__________________
Email:
_____________________________________________________
This disclosure can be used for the following purpose(s):
Legal
Insurance
Medical Certification
Other
Hospital and Medical Office records released as part of this authorization may contain references related to
mental health, addiction, and HIV medical conditions documented by primary care.
I authorize the following to be disclosed for the selected time frame:
Form Completion (a substitute form or relevant medical records may be released in lieu)
Medical Records
Diagnostic Images
Itemized Billing Records
Pharmacy Copays
Medical Copays
Time Frame: Last
2 months
6 months
1 year
2 years
5 years
All electronic records
Check the boxes below if you want this release to include the protected treating department or HIV initial
test result information. If not checked, this treating department information will be excluded.
Mental Health Treatment Records
Addiction Medicine Treatment Records
HIV Lab Test Results
Kaiser Permanente Oregon locations need to also check this box if they want Genetic Testing information released.
DURATION: Authorization shall remain in effect for 6 months from the date of signature below.
REVOCATION:
You or your personal representative may cancel this authorization for future releases by submitting
a written request to the Release of Information Unit listed for your region of service found on kp.org/requestrecords.
Your cancellation will not affect information that was released prior to receipt of the written request.
REDISCLOSURE: Once this information is released, it may not be protected under federal privacy law (HIPAA).
State or other federal law may require the recipient to obtain your authorization before further disclosure.
Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benefits on whether you
sign this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization,
and a note stating to whom your information was disclosed will be included in your medical record. A copy of the
original authorization is valid. You have a right to a copy of this completed authorization.
We will provide the requested information in electronic format to the recipient unless the recipient contact us to
make other arrangements.
Date Signature If personal representative, print name/relationship
NS-9934 (08-21) SPANISH-NS-1614; CHINESE-NS-6274
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
Instructions:
1) Complete the patient identification information on the top right-hand corner
2) Complete all required information for the recipient including a valid email address
3) Check the box for purpose of disclosure
4) Check the box(es) for the type of information to be disclosed and also check the box for a timeframe
5) If you want specially protected information to be included, check the appropriate box(es)
6) Enter the date you are signing the authorization
7) Sign the form
8) If you are a personal representative, print your name and relationship. We may reach out for you to provide
additional documentation if needed.
9) Submit this form to the third party you are authorizing to obtain records
10) Keep a copy for your records
“Kaiser Permanente” means both your insurance company (a Kaiser Permanente health plan) and your doctors
(a Permanente medical or dental group). It also includes different groups depending on where you live.
To find contact information go to kp.org and search locations for your region/market listed below or alternatively
go to kp.org/requestrecords and indicate your region/market.
All states where we do business:
• Kaiser Foundation Hospitals
• Kaiser Permanente Insurance Company
Colorado:
• Kaiser Foundation Health Plan of Colorado
• Colorado Permanente Medical Group, P.C.
Georgia:
• Kaiser Foundation Health Plan of Georgia, Inc.
• The Southeast Permanente Medical Group, Inc.
Mid-Atlantic (Maryland/Virginia/Washington, D.C.):
• Kaiser Foundation Health Plan of the
Mid-Atlantic States, Inc.
• Mid-Atlantic Permanente Medical Group, P.C.
Washington:
• Kaiser Foundation Health Plan of Washington
• Washington Permanente Medical Group, P.C.
California - North:
• Kaiser Foundation Health Plan, Inc., Northern California Region
• The Permanente Medical Group, Inc.
California - South:
• Kaiser Foundation Health Plan, Inc., Southern California Region
• Southern California Permanente Medical Group
Hawaii:
• Kaiser Foundation Health Plan, Inc., Hawaii
Region
• Hawaii Permanente Medical Group, Inc.
• Maui Health Systems
Northwest (Oregon/SW Washington):
• Kaiser Foundation Health Plan of the Northwest
• Northwest Permanente, P.C.
• Permanente Dental Associates, P.C.
Patient Name:
__________________________________________
Medical Record Number:
_________________________________
Birth Date:
___________
Email:
____________________________
Do not use for patient copies of or access to their medical records. Patients should go to kp.org/requestrecords
to conveniently request medical records, FMLA and Disability certifications.
AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION
To the Following Third-Party Recipient (Fees may be required)
Recipient Name:
______________________________________________________________________________
Address: ______________________________________________________________________________________
City:
___________________________________________________
State:
________
Zip Code:
______________
Phone # (
______
)
__________________ _____________________________________________________
Email:
This disclosure can be used for the following purpose(s):
Legal
Insurance
Medical Certification
Other
Hospital and Medical Office records released as part of this authorization may contain references related to
mental health, addiction, and HIV medical conditions documented by primary care.
I authorize the following to be disclosed for the selected time frame:
Form Completion (a substitute form or relevant medical records may be released in lieu)
Medical Records
Diagnostic Images
Itemized Billing Records
Pharmacy Copays
Medical Copays
Time Frame: Last
2 months
6 months
1 year
2 years
5 years
All electronic records
Check the boxes below if you want this release to include the protected treating department or HIV initial
test result information. If not checked, this treating department information will be excluded.
Mental Health Treatment Records
Addiction Medicine Treatment Records
HIV Lab Test Results
Kaiser Permanente Oregon locations need to also check this box if they want Genetic Testing information released.
DURATION: Authorization shall remain in effect for 6 months from the date of signature below.
REVOCATION:
You or your personal representative may cancel this authorization for future releases by submitting
a written request to the Release of Information Unit listed for your region of service found on kp.org/requestrecords.
Your cancellation will not affect information that was released prior to receipt of the written request.
REDISCLOSURE: Once this information is released, it may not be protected under federal privacy law (HIPAA).
State or other federal law may require the recipient to obtain your authorization before further disclosure.
Kaiser Permanente may not condition treatment, payment, enrollment, or eligibility for benefits on whether you
sign this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization,
and a note stating to whom your information was disclosed will be included in your medical record. A copy of the
original authorization is valid. You have a right to a copy of this completed authorization.
We will provide the requested information in electronic format to the recipient unless the recipient contact us to
make other arrangements.
Date Signature If personal representative, print name/relationship
NS-9934 (08-21) SPANISH-NS-1614; CHINESE-NS-6274
ORIGINAL - DISCLOSING PARTY CANARY - PATIENT
Document Specifics
| Fact Name | Description |
|---|---|
| Patient Identification | The form requires the patient's name, medical record number, birth date, and email address. |
| Purpose of Disclosure | Disclosures can be made for legal, insurance, medical certification, or other purposes. |
| Protected Information | The form allows for the inclusion of sensitive information such as mental health and HIV-related records. |
| Time Frame for Records | Patients can request records from the last 2 months, 6 months, 1 year, 2 years, 5 years, or all electronic records. |
| Duration of Authorization | The authorization remains valid for 6 months from the date of signature. |
| Revocation Process | Patients may revoke authorization by submitting a written request to the appropriate unit listed on kp.org/requestrecords. |
| Redisclosure Warning | Once information is released, it may not be protected under federal privacy law (HIPAA). |
| State-Specific Regulations | For Virginia patients, a copy of the authorization and a disclosure note will be included in their medical record. |
| Submission Instructions | Patients must complete the form and submit it to the designated third party to obtain records. |
Kaiser Records Request: Usage Instruction
Filling out the Kaiser Records Request form is a straightforward process that helps ensure your health information is shared with the right people. Once you complete the form, it will be submitted to the designated third party you wish to receive your records. Here’s how to fill it out step by step:
- Complete the patient identification information in the top right-hand corner, including your name, medical record number, birth date, and email address.
- Fill in all required details for the recipient, including their name, address, city, state, zip code, phone number, and a valid email address.
- Check the box that indicates the purpose of disclosure, such as legal, insurance, or medical certification.
- Check the box(es) for the type of information you want to be disclosed, and select a timeframe for the records.
- If you wish to include any specially protected information, check the appropriate box(es) for mental health, addiction medicine, or HIV lab test results.
- Enter the date you are signing the authorization.
- Sign the form to authorize the release of your information.
- If you are a personal representative, print your name and relationship to the patient.
- Submit the completed form to the third party you are authorizing to obtain the records.
- Keep a copy of the completed form for your records.
Learn More on Kaiser Records Request
What is the Kaiser Records Request form used for?
The Kaiser Records Request form is designed for individuals who wish to authorize the release of their health information to a third party. This may include medical records, billing information, or diagnostic images, among other types of health data. It is important to note that this form should not be used by patients seeking direct access to their own medical records.
How do I fill out the Kaiser Records Request form?
To complete the form, follow these steps:
- Fill in your personal identification information, including your name, medical record number, and date of birth.
- Provide the recipient's details, including their name, address, phone number, and email.
- Select the purpose for the disclosure by checking the appropriate box.
- Indicate the specific types of information you wish to disclose by checking the relevant boxes.
- Choose the time frame for which you want the information released.
- If applicable, check boxes for any specially protected information you want included.
- Sign and date the form.
- Keep a copy for your records and submit the form to the designated third party.
Who can I authorize to receive my health information?
You can authorize any third party, such as a legal representative, insurance company, or another healthcare provider, to receive your health information. Ensure that you provide their complete contact information on the form.
What types of information can be disclosed using this form?
The form allows for the disclosure of various types of health information, including:
- Medical records
- Diagnostic images
- Itemized billing records
- Pharmacy and medical copays
- Form completion
Additionally, you can request the inclusion of sensitive information, such as mental health treatment records, addiction medicine treatment records, and HIV lab test results.
How long does the authorization remain in effect?
The authorization you provide will remain valid for six months from the date you sign the form. After this period, a new authorization will be necessary for any further disclosures.
Can I revoke my authorization once it has been submitted?
Yes, you have the right to revoke your authorization at any time. To do this, you must submit a written request to the Release of Information Unit for your region. However, revocation will not affect any information that has already been released prior to the receipt of your cancellation request.
What should I do if I have questions about the form?
If you have questions or need assistance while completing the Kaiser Records Request form, it is advisable to contact the Release of Information Unit for your specific region. They can provide guidance and address any concerns you may have regarding the process.
Is my information protected after it is disclosed?
Once your health information is released to a third party, it may no longer be protected under federal privacy laws, such as HIPAA. It is essential to understand that the recipient may be required to obtain your authorization for any further disclosures of that information.
Common mistakes
When filling out the Kaiser Records Request form, individuals often make several common mistakes that can delay the process. One frequent error involves incomplete patient identification information. It is crucial to fill out all fields, including the Patient Name, Medical Record Number, and Birth Date. Omitting any of this information can lead to confusion and may result in the request being rejected or delayed.
Another mistake occurs when the recipient's information is not provided accurately. The form requires specific details such as the Recipient Name, Address, and Email. If any of this information is incorrect or missing, it can hinder the timely delivery of the requested records. Additionally, it is important to ensure that the email address is valid, as this is often the primary method of communication regarding the request.
Many people also overlook the importance of selecting the appropriate purpose for the disclosure. The form includes checkboxes for various purposes, such as Legal, Insurance, and Medical Certification. Failing to check the relevant box can result in the request not being processed correctly, as it may not align with the intended use of the information.
Lastly, individuals sometimes forget to sign and date the authorization section of the form. This step is essential, as the authorization will not be valid without a signature. Furthermore, if a personal representative is signing on behalf of the patient, it is necessary to include their name and relationship to the patient. Neglecting this detail can lead to additional requests for information and further delays in obtaining the medical records.
Documents used along the form
When requesting medical records, there are several other forms and documents that may be required or helpful in conjunction with the Kaiser Records Request form. Here’s a list of commonly used documents:
- Authorization for Release of Medical Records: This document grants permission for healthcare providers to share a patient's medical records with a designated third party.
- Patient Identification Form: This form verifies the identity of the patient requesting their medical records, ensuring that sensitive information is protected.
- HIPAA Privacy Notice: This notice outlines patients' rights under the Health Insurance Portability and Accountability Act, including how their health information may be used and disclosed.
- FMLA Certification Form: Used to request leave under the Family and Medical Leave Act, this form may require medical information to substantiate the request.
- Disability Certification Form: This document certifies a patient's eligibility for disability benefits, often requiring detailed medical information.
- Itemized Billing Statement: This form provides a detailed account of medical services rendered and associated costs, useful for insurance claims or personal records.
- Power of Attorney for Healthcare: This legal document allows a designated individual to make healthcare decisions on behalf of the patient if they are unable to do so.
- Genetic Testing Consent Form: This form is necessary if a patient wishes to undergo genetic testing and ensures they understand the implications of the testing.
- Release of Information Consent Form: This document allows a patient to authorize the release of their medical information to specific entities, such as insurance companies or legal representatives.
Understanding these forms can simplify the process of obtaining medical records and ensure that all necessary information is accurately shared. Each document serves a specific purpose, contributing to a smoother experience when dealing with healthcare records.
Similar forms
The Authorization for Release of Medical Information form is similar to the Kaiser Records Request form in that both documents require patient identification details and specify the recipient of the medical records. Each form outlines the purpose for which the records are requested, such as legal, insurance, or medical certification. They also include options for the type of information to be disclosed, ensuring that the patient can control what is shared and with whom.
The HIPAA Authorization form serves a similar purpose by allowing patients to authorize the release of their health information. Like the Kaiser form, it requires patient identification and specifies the recipient. The HIPAA Authorization form also highlights the potential for redisclosure of information, which is a crucial aspect for patients to understand. This ensures that patients are aware of the privacy implications when their information is shared with third parties.
The Medical Records Release form is another document that parallels the Kaiser Records Request form. Both forms require the patient's name, medical record number, and other identifying information. They also outline the specific types of records being requested, such as medical history or diagnostic images. This standardization helps streamline the process of obtaining medical records across different healthcare providers.
The Disability Certification Request form shares similarities with the Kaiser Records Request form by allowing patients to authorize the release of their medical records for specific purposes, such as applying for disability benefits. Both forms require patient information and detail the types of records to be disclosed. This ensures that the necessary documentation is provided to support the patient's claim.
The FMLA (Family and Medical Leave Act) Certification form is also akin to the Kaiser Records Request form. It allows patients to request the release of their medical information to support their leave from work due to medical reasons. Both forms require patient identification and specify the purpose of the information request, ensuring that the patient's needs are adequately addressed while protecting their privacy.
Lastly, the Patient Information Release Authorization form is similar in structure and function to the Kaiser Records Request form. Both require patient details and specify the recipient of the information. They also provide options for the types of records to be released, empowering patients to make informed decisions about their health information. This consistency across forms helps patients navigate the process of obtaining their medical records efficiently.
Dos and Don'ts
When filling out the Kaiser Records Request form, it’s important to follow specific guidelines to ensure a smooth process. Here are some do's and don'ts to keep in mind:
- Do complete all required patient identification information at the top of the form.
- Do provide a valid email address for the recipient.
- Do check the appropriate box for the purpose of disclosure.
- Do indicate the type of information you want to be disclosed.
- Do specify the timeframe for the records you are requesting.
- Don't forget to sign the form where indicated.
- Don't leave any required fields blank.
- Don't submit the form without keeping a copy for your records.
- Don't use this form if you are a patient seeking your own records; visit kp.org/requestrecords instead.
Misconceptions
Understanding the Kaiser Records Request form is essential for patients and third-party recipients alike. However, several misconceptions can lead to confusion. Here are seven common misconceptions:
- This form can be used to request personal medical records directly. In reality, patients should use kp.org/requestrecords for their own medical records.
- There are no fees associated with using the form. Fees may be required for certain disclosures, depending on the recipient and the type of information requested.
- All medical information can be disclosed without restrictions. Certain sensitive information, like mental health records and HIV test results, requires explicit consent to be included.
- The authorization lasts indefinitely. The authorization is only valid for six months from the date of signature, after which a new request is necessary.
- Once the information is released, it remains protected under HIPAA. After disclosure, the information may not be protected, and further sharing by the recipient may require additional authorization.
- Only the patient can revoke the authorization. A personal representative can also cancel the authorization by submitting a written request.
- All states have the same rules regarding the form. Different states may have varying requirements and regulations, which can affect how the form is processed.
Being informed about these misconceptions can help ensure that the process of requesting medical records is smooth and compliant with legal requirements. Take action now to clarify any doubts and ensure proper handling of sensitive health information.
Key takeaways
Filling out and using the Kaiser Records Request form can be straightforward if you understand the key points. Here are some important takeaways to keep in mind:
- The form is not for patients to request their own medical records. Instead, patients should visit kp.org/requestrecords for their requests.
- Complete all required fields accurately, including patient identification and recipient information. This ensures that the request is processed without delays.
- You must indicate the purpose of the disclosure by checking the appropriate box. Options include legal, insurance, or medical certification.
- Specify the type of information you want disclosed, such as medical records or billing records, and select the time frame for which you need the information.
- If you wish to include sensitive information, such as mental health or HIV-related records, be sure to check the relevant boxes.
- Authorization remains valid for six months. If you wish to revoke this authorization, you can do so by submitting a written request to the appropriate unit.
- Once the information is released, it may not be protected under federal privacy laws. Be aware that state laws may require additional authorization for further disclosure.