California Authorization For Disclosure of Patient Health Information
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Patient Name: _____________________________
Kaiser # _______________ Date of Birth: ________
Kaiser Foundation Hospitals
Permanente Medical Groups
Address: __________________________________
City: _____________________________________
AUTHORIZATION FOR USE OR DISCLOSURE
State: __________________ Zip Code: _________
OF PATIENT HEALTH INFORMATION
(
)
Telephone Number: _________________________
Note: Fees may apply to certain requests
Email: ____________________________________
Kaiser Permanente will not condition treatment, payment, enrollment or
eligibility for benefits on providing, or refusing to provide this authorization.
This authorizes the following Kaiser Permanente
Medical Center(s): __________________________
__________________________________________
To: q Produce a copy of medical records as
specified below
q Complete form(s) (Please specify form
type(s) in the PURPOSE section below)
q Allow named KP physician to view records

Kaiser Permanente may disclose