Kaiser Records Request Template

Kaiser Records Request Template

The Kaiser Records Request form is a document that allows individuals to authorize the release of their health information to a third party. This form is essential for anyone needing to share their medical records for purposes such as legal matters, insurance claims, or medical certifications. If you need to fill out the form, please click the button below.

Table of Contents

The Kaiser Records Request form is a vital tool for individuals seeking to authorize the release of their health information to a third party. This form captures essential details, including the patient’s name, medical record number, and birth date, ensuring that the request is tied to the correct individual. It is important to note that this form is not intended for patients to access their own medical records directly; instead, they should utilize the kp.org/requestrecords website for that purpose. The form allows patients to specify the recipient of the records and the purpose for which the information will be used, such as legal or insurance needs. Additionally, it offers options for disclosing specific types of information, including mental health records and HIV test results, which require careful consideration. Patients can select a time frame for which records are requested, ranging from the last two months to five years, or even all electronic records. With clear instructions for completion and a defined duration for the authorization, this form plays a crucial role in managing patient health information while adhering to privacy laws. Understanding how to navigate this form can empower individuals to take control of their health records and ensure their information is shared appropriately.

Kaiser Records Request Sample

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.

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 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
▼ Kaiser Records Request PDF Form

Document Attributes

Fact Name Fact Description
Patient Identification The form requires the patient's name, medical record number, birth date, and email address for identification purposes.
Third-Party Disclosure Patients must specify a third-party recipient for the health information, including their name, address, and contact details.
Purpose of Disclosure The form allows patients to indicate the purpose of the information request, such as legal, insurance, or medical certification.
Protected Information Patients can choose to include sensitive information related to mental health, addiction, and HIV lab test results in the disclosure.
Duration of Authorization The authorization for disclosure remains valid for six months from the date of the signature.
Revocation Process Patients can revoke the authorization at any time by submitting a written request to the appropriate Release of Information Unit.
Redisclosure Warning Once released, the information may not be protected under federal privacy laws, and further disclosure may require additional authorization.
State-Specific Laws For Virginia patients, a copy of the authorization and a note on the disclosure will be included in their medical records, as mandated by state law.

Kaiser Records Request: Usage Instruction

After completing the Kaiser Records Request form, the next step involves submitting it to the designated third party you have authorized to obtain the records. Make sure to keep a copy for your personal records. This process ensures that your request is handled efficiently and that your information is shared appropriately.

  1. Complete the patient identification information at the top right-hand corner, including your name, medical record number, birth date, and email.
  2. Fill in all required information for the recipient, ensuring to include a valid email address.
  3. Check the box indicating the purpose of disclosure.
  4. Check the box(es) for the type of information you want disclosed and select a timeframe.
  5. If you wish to include specially protected information, check the appropriate box(es) for mental health, addiction medicine, or HIV lab test results.
  6. Enter the date you are signing the authorization.
  7. Sign the form to validate your request.
  8. If you are acting as a personal representative, print your name and relationship to the patient.
  9. Submit the completed form to the third party you have authorized to obtain the records.
  10. Keep a copy of the signed authorization for your records.

Frequently Asked Questions

  1. 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 medical records to a third party. This can include legal, insurance, or medical certification purposes. It is important to note that patients should not use this form for personal copies of their medical records; instead, they should visit kp.org/requestrecords.

  2. Who can I authorize to receive my medical records?

    You can authorize any third-party recipient, such as an attorney, insurance company, or another healthcare provider. It is essential to provide accurate details, including the recipient's name and address, to ensure proper delivery of the records.

  3. What types of information can be disclosed using this form?

    The form allows you to request the release of various types of information, including:

    • Medical records
    • Diagnostic images
    • Itemized billing records
    • Pharmacy copays
    • Medical copays

    Additionally, you can opt to include sensitive information related to mental health, addiction, or HIV lab test results.

  4. How long is the authorization valid?

    The authorization for the release of information remains in effect for six months from the date you sign the form. After this period, a new authorization will be required to release additional information.

  5. Can I revoke my authorization after I have signed the form?

    Yes, you can revoke your authorization at any time. To do so, you must submit a written request to the Release of Information Unit for your region, as indicated on kp.org/requestrecords. However, revoking the authorization will not affect any information that was already released prior to your request.

  6. What should I do if I want to include sensitive health information?

    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.

  7. What happens if I do not provide a valid email address for the recipient?

    Providing a valid email address for the recipient is crucial for ensuring that the records are sent correctly. If an email address is not provided, there may be delays in processing your request, or the records may not be sent electronically.

  8. Is there a fee associated with requesting my medical records?

    Fees may apply when releasing medical records to a third party. It is advisable to check with the specific department handling the request for any potential costs involved.

  9. Can I receive a copy of the completed authorization?

    Yes, you have the right to obtain a copy of the completed authorization form. It is recommended to keep this copy for your records.

  10. Where can I find additional information about the Kaiser Records Request process?

    For more details, including instructions and contact information for your specific region, visit kp.org/requestrecords. This site provides comprehensive resources for managing your medical records requests.

Common mistakes

Filling out the Kaiser Records Request form can seem straightforward, but mistakes can happen. One common error is leaving out essential patient identification information. This includes the patient's name, medical record number, and birth date. Missing any of these details can delay the processing of the request.

Another mistake is not providing complete information for the third-party recipient. If the recipient's name, address, or email is incorrect or incomplete, it can lead to confusion. This may result in the records being sent to the wrong person or not being sent at all.

People often forget to check the purpose of disclosure box. This step is crucial because it clarifies why the records are being requested. Without this information, the request may not be processed correctly. Always remember to select a purpose, such as legal or insurance.

Additionally, some individuals overlook the time frame for which they are requesting records. Whether it’s for the last 2 months or 5 years, it’s important to specify this clearly. Not doing so can lead to receiving records that are not relevant to the current needs.

Another common oversight is neglecting to check the boxes for specially protected information, such as mental health or HIV lab test results. If you want this sensitive information included, make sure to check the appropriate boxes. Failing to do so means that this information will be excluded from the request.

Finally, many forget to sign the form or enter the date. This step is necessary for the authorization to be valid. Without a signature and date, the request cannot be processed. Always double-check that you’ve completed all necessary fields before submitting the form.

Documents used along the form

The Kaiser Records Request form is an essential document for obtaining patient health information. Along with this form, several other documents may be required or helpful in the process of managing medical records. Below is a list of commonly used forms and documents that often accompany the Kaiser Records Request form.

  • Patient Authorization Form: This form grants permission for the release of specific medical records to designated third parties. It outlines the information being shared and the purpose of the disclosure.
  • Medical Records Release Form: Similar to the authorization form, this document is specifically designed for requesting the release of medical records from healthcare providers.
  • FMLA Certification Form: This form is used to certify a patient's need for leave under the Family and Medical Leave Act. It may require medical documentation to support the request.
  • Disability Certification Form: Patients use this document to request verification of their medical condition for disability benefits. It typically requires detailed medical information from a healthcare provider.
  • Insurance Claim Form: This form is submitted to insurance companies to request reimbursement for medical expenses. It includes details about the services received and the associated costs.
  • Patient Identification Form: This document verifies the identity of the patient requesting records. It usually includes personal information such as name, date of birth, and contact details.
  • Genetic Testing Authorization Form: Required for patients seeking to disclose genetic testing results, this form ensures that the release of sensitive information is properly authorized.

Each of these documents plays a vital role in the management of medical records and the protection of patient information. Proper completion and submission can streamline the process of obtaining necessary health records and certifications.

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 specified third parties. Both require patient identification and specify the purpose of disclosure.
  • Medical Records Release Form: This form is used to request access to medical records from healthcare providers. Like the Kaiser form, it requires patient details and information about the recipient.
  • FMLA Certification Form: This document is used to request medical information for Family and Medical Leave Act purposes. It shares the need for specific patient information and the purpose of the disclosure.
  • Disability Certification Form: Similar in function, this form requests medical information for disability claims. It also requires details about the patient and the intended use of the information.
  • Patient Consent Form: This form grants permission for healthcare providers to share patient information. It mirrors the Kaiser form in that it necessitates patient consent and outlines the scope of information to be shared.
  • Insurance Claim Form: Used to submit claims to insurance companies, this form collects patient information and medical details. Both forms aim to facilitate the exchange of health information for specific purposes.
  • Power of Attorney for Healthcare: This document allows a designated individual to make healthcare decisions on behalf of a patient. Like the Kaiser form, it involves the authorization of information sharing but focuses on decision-making authority.
  • Release of Information Request: This form is used to request the release of health records for various purposes. It shares similarities with the Kaiser form in requiring patient information and specifying the recipient.

Dos and Don'ts

When filling out the Kaiser Records Request form, there are important dos and don'ts to keep in mind. Here’s a helpful list:

  • Do complete all required fields accurately, including your name and medical record number.
  • Do provide a valid email address for the third-party recipient.
  • Do check the appropriate boxes for the purpose of disclosure.
  • Do keep a copy of the completed form for your records.
  • Do sign and date the form to make it valid.
  • Don't submit the form without filling in all required information.
  • Don't forget to specify the timeframe for the records you want disclosed.
  • Don't leave out any special information you want included, such as mental health records.
  • Don't use this form for personal access to your own medical records; use kp.org/requestrecords instead.
  • Don't assume the information will remain confidential after it is released.

Misconceptions

  • Misconception 1: The Kaiser Records Request form is for patients to access their own medical records.

    • This form is specifically designed for authorizing the release of information to a third party, not for patients to obtain their own records. Patients should visit kp.org/requestrecords for personal requests.

  • Misconception 2: Completing the form guarantees immediate access to medical records.
  • Misconception 3: There are no fees associated with using the Kaiser Records Request form.

    • Fees may apply when releasing information to third parties. It is essential to check with the recipient regarding any potential costs.

  • Misconception 4: The form allows for unlimited access to all medical records.

    • The authorization is limited to specific records and timeframes as indicated by the requester. It is crucial to check the appropriate boxes for the desired information.

  • Misconception 5: Patients can revoke their authorization at any time without any consequences.

    • While patients can revoke the authorization for future releases, this does not affect any information that has already been released before the revocation request was received.

  • Misconception 6: The form includes all types of medical information by default.

    • Protected information, such as mental health records or HIV test results, must be specifically requested by checking the appropriate boxes on the form.

  • Misconception 7: Once the records are released, they remain confidential under HIPAA.

    • After the information is disclosed, it may no longer be protected under federal privacy laws. The recipient may have different obligations regarding further disclosure.

  • Misconception 8: The form is the same for all Kaiser Permanente locations.

    • The form may vary based on the specific Kaiser Permanente region or market. Always ensure you are using the correct version for your location.

Key takeaways

Key Takeaways for Filling Out and Using the Kaiser Records Request Form:

  • Complete all required patient information at the top of the form, including name, medical record number, birth date, and email.
  • This form is not for patients to access their own medical records. Patients should visit kp.org/requestrecords for that purpose.
  • Clearly identify the third-party recipient by providing their name, address, phone number, and email address.
  • Indicate the purpose of the disclosure by checking the appropriate box (e.g., legal, insurance, medical certification).
  • Select the specific types of information to be disclosed, such as medical records, diagnostic images, or billing records.
  • Specify the time frame for the records requested, ranging from the last 2 months to all electronic records.
  • For sensitive information, check the relevant boxes to include mental health, addiction treatment records, or HIV test results.
  • Keep a copy of the completed form for your records and submit it to the designated third party.