Outline
When seeking access to medical records or authorizing the disclosure of health information, the Kaiser Records Request form serves as a crucial tool for patients. This form is designed for individuals who need to share their medical information with a third party, such as an insurance company or legal representative. It requires essential patient details, including the patient's name, medical record number, and birth date. Notably, this form is not intended for patients to directly obtain their own medical records; instead, they should utilize kp.org/requestrecords for that purpose. The form outlines the authorization for the use or disclosure of patient health information, specifying the recipient's name and contact information, as well as the purpose of the disclosure, which may include legal, insurance, or medical certification needs. Patients can choose the types of records they wish to disclose, such as medical records, diagnostic images, and billing records, while also indicating the time frame for which the information is requested. Additionally, there are options to include sensitive information related to mental health or HIV testing, ensuring that patients can tailor the request to their specific needs. Understanding the duration of the authorization and the process for revocation is also vital, as it empowers patients to manage their health information effectively.
Sample - 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
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
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Diagnostic Images |
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Itemized Billing Records |
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Pharmacy Copays |
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Medical Copays |
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Time Frame: Last |
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2 months |
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6 months |
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1 year |
2 years |
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5 years |
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All electronic records |
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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.
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Date |
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Signature |
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If personal representative, print name/relationship |
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ORIGINAL - DISCLOSING PARTY CANARY - PATIENT |
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Instructions:
1)Complete the patient identification information on the top
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.
•Kaiser Foundation Health Plan of the
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Washington:
•Kaiser Foundation Health Plan of Washington
•Washington Permanente Medical Group, P.C.
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.
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
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
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.
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Date |
Signature |
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If personal representative, print name/relationship |
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ORIGINAL - DISCLOSING PARTY CANARY - PATIENT |
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Form Information
| Fact Name | Details |
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| Patient Identification | The form requires the patient's name, medical record number, birth date, and email address for proper identification. |
| Third-Party Disclosure | Patients can authorize the release of their health information to a third party, which may involve fees. |
| Duration of Authorization | The authorization remains valid for six months from the date it is signed, allowing for timely use of the information. |
| Revocation Process | Patients can revoke their authorization by submitting a written request, which will not affect previously released information. |
| State-Specific Regulations | In Virginia, a copy of the authorization and a disclosure note will be included in the patient's medical record, as mandated by state law. |
Detailed Guide for Filling Out Kaiser Records Request
Filling out the Kaiser Records Request form is a straightforward process that allows you to authorize the release of your medical information to a designated third party. Once completed, you will submit the form to the recipient you have chosen, and they will handle the request from there.
- Complete the patient identification information at the top right-hand corner of the form.
- Fill in all required details for the recipient, including a valid email address.
- Check the box indicating the purpose of the disclosure.
- Select the type of information you want to be disclosed by checking the appropriate box(es) and choose a timeframe for the records.
- If you wish to include specially protected information, check the relevant box(es).
- Enter the date you are signing the authorization.
- Sign the form to confirm your request.
- 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 form for your own records.
Obtain Answers on Kaiser Records Request
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What is the Kaiser Records Request form used for?
The Kaiser Records Request form allows patients to authorize the release of their health information to a third party. This can include medical records, billing information, and diagnostic images. It is important to note that this form is not for patients to access their own medical records directly.
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How do I request my medical records as a patient?
Patients should visit kp.org/requestrecords to conveniently request their medical records. This online platform also allows for requests related to FMLA and disability certifications.
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What information do I need to provide on the form?
You will need to fill out your name, medical record number, birth date, and email address at the top of the form. Additionally, provide details about the third-party recipient, including their name, address, phone number, and email.
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What types of information can be disclosed using this form?
The form allows for the disclosure of various types of information, such as:
- Medical records
- Diagnostic images
- Itemized billing records
- Pharmacy copays
- Medical copays
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How long is the authorization valid?
The authorization remains in effect for six months from the date you sign the form. After that period, you will need to submit a new request if you want to continue the disclosure.
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Can I revoke my authorization after signing the form?
Yes, you can revoke your authorization at any time by submitting a written request to the Release of Information Unit for your region. However, this cancellation will not affect any information that was already released prior to your request.
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What happens to my information once it is released?
Once your information is released, it may no longer be protected under federal privacy laws such as HIPAA. The recipient may be required by state or other federal laws to obtain your authorization before disclosing the information further.
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What if I want to include sensitive information in the release?
If you wish to include sensitive information, such as mental health treatment records or HIV lab test results, you must check the appropriate boxes on the form. If these boxes are not checked, that information will be excluded from the disclosure.
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Where can I find contact information for Kaiser Permanente?
You can find contact information for Kaiser Permanente by visiting kp.org and searching for locations in your region. This will help you connect with the appropriate services based on where you live.
Common mistakes
Filling out the Kaiser Records Request form can be straightforward, but there are common mistakes that people often make. One frequent error is not providing complete patient identification information. The form requires specific details such as the patient's name, medical record number, and birth date. Omitting any of these details can delay the processing of the request.
Another mistake involves the recipient information section. It is essential to include accurate details for the third-party recipient, including a valid email address. If this information is incorrect or missing, the request may not reach the intended party. This can lead to unnecessary delays in obtaining the medical records.
People also tend to overlook the purpose of disclosure section. It is important to check the appropriate box indicating why the records are being requested, such as for legal or insurance purposes. Failing to do so may result in the request being deemed incomplete, which can further postpone access to the needed information.
Lastly, many individuals forget to sign and date the form. This step is crucial, as the authorization must be valid to process the request. Without a signature, the form cannot be accepted, and the request will not be fulfilled. Taking the time to review the entire form before submission can help avoid these common pitfalls.
Documents used along the form
When requesting medical records from Kaiser Permanente, you may come across several other forms and documents that can assist in the process. Understanding these documents will help ensure that you have everything you need for your request.
- Authorization for Release of Medical Records: This form allows you to authorize the release of your medical records to a specified third party. It includes details like the recipient's information and the purpose of the disclosure.
- Patient Information Form: This document collects essential details about you, such as your name, date of birth, and contact information. It ensures that your records are accurately matched to your identity.
- FMLA Certification Form: If you're requesting medical records for Family and Medical Leave Act purposes, this form certifies your need for leave due to health issues.
- Disability Certification Form: This form is used to certify a disability when applying for benefits. It requires specific medical information to support your claim.
- Request for Itemized Billing: If you need a detailed breakdown of your medical charges, this form requests an itemized bill from your healthcare provider.
- Pharmacy Record Request: This document allows you to request records related to your prescriptions, including history and billing information.
- Genetic Testing Release Form: If you want to authorize the release of genetic testing results, this form is necessary, especially in certain states like Oregon.
- Patient Revocation of Authorization: If you decide to cancel a previously signed authorization, this form allows you to formally revoke permission for future disclosures.
- HIPAA Privacy Notice: This document outlines your rights under the Health Insurance Portability and Accountability Act (HIPAA) concerning your medical records and privacy.
By familiarizing yourself with these forms, you can streamline the process of obtaining your medical records and ensure that your requests are handled efficiently. Always keep copies of your submitted documents for your records.
Similar forms
- HIPAA Authorization Form: Similar to the Kaiser Records Request form, this document allows patients to authorize the release of their health information to specific third parties. Both forms require patient identification and specify the purpose of the disclosure.
- Medical Records Release Form: This form is used to request copies of medical records from healthcare providers. Like the Kaiser form, it includes sections for patient information and recipient details, ensuring that sensitive information is shared appropriately.
- FMLA Certification Form: This document is used for Family and Medical Leave Act requests. It shares similarities with the Kaiser form in that it requires patient consent and specifies the type of medical information to be disclosed for employment-related purposes.
- Disability Insurance Claim Form: Patients use this form to claim benefits for disability. It parallels the Kaiser Records Request form by requiring medical documentation and patient authorization for information release.
- Patient Authorization for Release of Information: This is a general form used by many healthcare providers to obtain permission to share patient information. Both forms emphasize patient consent and detail the specific information being released.
- Consent for Treatment Form: While primarily focused on treatment consent, this form also includes sections for authorizing the sharing of medical information. It reflects the patient-centered approach found in the Kaiser Records Request form.
- Insurance Claim Form: This document is used to file a claim with an insurance company. Similar to the Kaiser form, it may require medical records to be released to support the claim, thus necessitating patient authorization.
- Psychiatric Records Release Form: Specifically for mental health records, this form allows patients to authorize the release of sensitive information. It shares the same protective measures for confidentiality as the Kaiser Records Request form.
- Genetic Information Release Form: This form is used to disclose genetic testing results to third parties. Like the Kaiser form, it requires patient consent and specifies the type of information being shared.
- Substance Abuse Treatment Records Release Form: This document is used to authorize the release of records related to substance abuse treatment. It mirrors the Kaiser form's emphasis on protecting sensitive health information while allowing for necessary disclosures.
Dos and Don'ts
When filling out the Kaiser Records Request form, it’s important to approach the task with care and attention to detail. Here are some key do's and don'ts to keep in mind:
- Do complete all required fields accurately to avoid delays.
- Do provide a valid email address for the recipient to ensure smooth communication.
- Do check the appropriate boxes for the purpose of disclosure and the type of information you wish to release.
- Do keep a copy of the completed form for your records.
- Don't forget to sign and date the form before submission.
- Don't leave any required fields blank, as this may lead to processing issues.
- Don't use this form for personal copies of your medical records; instead, visit kp.org/requestrecords.
- Don't assume that all requested information will be released without checking the appropriate boxes for sensitive information.
By following these guidelines, you can help ensure that your request is processed efficiently and accurately. Remember, this process is designed to protect your health information while making it accessible when needed.
Misconceptions
- Misconception 1: The Kaiser Records Request form can be used by patients to obtain their own medical records.
- Misconception 2: There are no fees associated with using the Kaiser Records Request form.
- Misconception 3: The authorization remains valid indefinitely once signed.
- Misconception 4: All types of medical information are automatically included in the disclosure.
- Misconception 5: Patients can revoke the authorization at any time without any conditions.
- Misconception 6: The information released is always protected under HIPAA.
This is incorrect. Patients must go to kp.org/requestrecords to request their medical records directly. The form is intended for authorizing third parties to access records.
Fees may be required for the disclosure of information to a third party. It is important to check with the specific recipient regarding any potential charges.
The authorization is only valid for six months from the date of signature. After this period, a new authorization must be submitted for further disclosures.
Specific types of information, such as mental health treatment records and HIV test results, must be explicitly requested by checking the appropriate boxes on the form.
While patients can revoke the authorization, they must submit a written request to the Release of Information Unit. The revocation does not affect any information already released prior to the request.
Once the information is disclosed to a third party, it may not be protected under federal privacy law. Recipients may need to obtain further authorization for any additional disclosures.
Key takeaways
When filling out and using the Kaiser Records Request form, keep these key takeaways in mind:
- Purpose of the Form: This form is specifically designed for authorizing the release of your health information to a third party. It is not intended for patients to request their own medical records directly.
- Required Information: Ensure you complete all necessary fields, including your name, medical record number, and the recipient's contact details. An accurate email address for the recipient is crucial.
- Selecting Information: Clearly indicate what type of information you wish to disclose. Options include medical records, diagnostic images, and itemized billing records.
- Time Frame: You can specify a time frame for the records you want released, ranging from the last two months to five years, or even all electronic records.
- Special Protections: If you want to include sensitive information, such as mental health or HIV-related records, make sure to check the appropriate boxes on the form.
- Revocation Rights: You have the right to revoke your authorization at any time by submitting a written request. However, this will not affect any information already released.
Following these guidelines will help ensure that your request is processed smoothly and efficiently.