Edit, Download, and Sign the Kaiser Permanente Patient Record Authorization Form
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How do I fill this out?
Filling out this form is straightforward. Ensure you have all the necessary patient and recipient information ready. Carefully follow the instructions provided to avoid any processing delays.
How to fill out the Kaiser Permanente Patient Record Authorization Form?
1
Print the patient information accurately.
2
Complete the recipient information section.
3
Indicate the purpose of the information release.
4
Provide the details on the information to be released.
5
Sign and date the authorization.
Who needs the Kaiser Permanente Patient Record Authorization Form?
1
Doctors who need to obtain patient records for treatment.
2
Legal representatives needing medical documents for a case.
3
Insurance companies requiring records for claim processing.
4
Patients wanting access to their personal health information.
5
Employers needing FMLA documentation for employee leave.
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What are the instructions for submitting this form?
To submit the completed authorization form, please choose the appropriate regional mailing address or fax number based on your location. For Western Washington, send to Kaiser Foundation Health Plan of Washington, Release of Information, MAILSTOP: RCG-D1N-02, PO Box 9010, Renton, WA 98057-9054 (Fax: 877-848-6896). For Eastern Washington, send to MAILSTOP: ACN-AC3, PO Box 204, Spokane, WA 99210-9809 (Fax: 855-414-1751). For radiology images, fax requests to the Central Imaging Center.
What are the important dates for this form in 2024 and 2025?
This form does not have major annual deadlines but is subject to changes based on Kaiser Permanente's policy updates. Users should ensure they are using the most current version available for all requests.
What is the purpose of this form?
The purpose of this form is to provide authorization for the release of patient health information to designated individuals or organizations. It is crucial for ensuring that patient privacy is maintained while still allowing necessary medical and legal access to health records. This document serves as a vital tool for patients navigating their health information needs.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Information: Required details about the patient including name, medical record number, and contact information.
- 2. Recipient Information: Information about the person or organization receiving the records.
- 3. Delivery Method: Options for delivering the records such as email, fax, or patient online accounts.
- 4. Purpose of Release: Indicates the reason for requesting the records.
- 5. Information to be Released: Specifies what type of records are being requested and the relevant dates.
- 6. Patient Authorization: Section where the patient signs to authorize release of information.
- 7. Expiration: Indicates when the authorization will expire.
What happens if I fail to submit this form?
Failure to submit this form may result in delays in processing your request for medical records. Without proper authorization, your health information cannot be released to the designated recipient.
- Processing Delays: Incomplete forms can lead to significant delays in obtaining needed health information.
- Legal Implications: Unauthorized release may have legal ramifications under health privacy laws.
- Missed Appointments: Delays in accessing health records may affect timely medical appointments.
How do I know when to use this form?
- 1. Medical Treatment: Used by healthcare providers to obtain necessary records for ongoing treatment.
- 2. Legal Claims: Required for lawyers or legal representatives to access medical documents in case of litigation.
- 3. Insurance Processing: Needed by insurance companies for verifying claims and benefits.
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