[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-283779-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-283779-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","act-for-a-family-member-via-kaiser-permanenteorg-health-information-access-authorization-form","Act for a Family Member via Kaiser Permanente.org - Health Information Access Authorization Form","","Health Information Management Services authorization form enabling a designated proxy to access a patient’s protected health information via Kaiser Permanente.org. The form collects patient identity details and proxy/legal representative information, including relationship, medical record number, date of birth, and contact information. It explains that released records may include treatment for physical and mental illness, substance use, and HIV/AIDS-related information. It specifies activation within 60 days of signing, validity for up to two years, options to discontinue online access, and how written revocation must be submitted.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/act-for-a-family-member-via-kaiser-permanenteorg-health-information-access-authorization-form/283779/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/act-for-a-family-member-via-kaiser-permanenteorg-health-information-access-authorization-form/283779.png","ImageObject",442,249,{"name":42,"@type":43},"Dipper","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",19,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who can be authorized to access the patient’s protected health information?","Question",{"text":63,"@type":64},"A patient’s designated proxy and/or legal representative can be authorized, including legal guardian, durable power of attorney for health care, or a healthcare agent.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What types of medical information may be released under this authorization?",{"text":68,"@type":64},"Released information may include physical and mental illness treatment, alcohol or drug abuse information, HIV/AIDS test results, HIV/AIDS diagnosis or treatment, and past medical history.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the authorization valid and when must online access be activated?",{"text":72,"@type":64},"Online access must be activated within 60 days of signing, and the authorization remains valid for a period not to exceed two (2) years.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283779,1790209756,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":22,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":4},1374404997633,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd","Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.  \n2101 E. Jefferson Street, Rockville, MD 20849-6611  \nAct [for a Family Member via](for a Family Member via Kaiser Permanente.org)[ Kaiser Permanente.org](for a Family Member via Kaiser Permanente.org) ([Kp.org](Kp.org)) Access Authorization Form  \nDiminished Capacity Individual’s Information:  \nI authorize Kaiser Permanente Foundation Health Plan and/or The Mid-Atlantic Permanente Medical Group, [Inc. to](Inc. to)[ ](Inc. to)disclose protected health information [via Kaiser Permanante.org](via Kaiser Permanante.org) for the patient named below:  \nPatient Name:   Medical Record \\#:  Address:   City/State/Zipcode:    \nTelephone \\#: (  )   Patient’s Date of Birth  / /   \nDesignated Proxy (Legal Representative) Information:  \nI authorize Kaiser Permanente Foundation Health Plan and/or The Mid-Atlantic Permanente Medical Group, [Inc. to](Inc. to)[ ](Inc. to)disclose protected health information [on Kaiser Permanante.org](on Kaiser Permanante.org) for the patient named below:  \nName of Person to Have Access Kaiser Medical Record Number  \nDate of Birth:  / /  Telephone \\#: (  )   \nRelationship to Patient:  Legal Guardian**  Durable Power of Attorney for Health  HealthCare Agent Form **If the Legal Guardian, Durable Power of Attorney for Health Care or a Healthcare Agent, a copy of the supporting documentation must be attached to this form  \nPatient or Patient’s authorized legal representative must sign below  \nI understand that the information released upon authority of this authorization may include information regarding the patient’s treatment for physical and mental illness, alcohol/drug abuse, HIV/AIDS test results, diagnosis or treatment of HIV/AIDS, and past medical history information. I understand that I may discontinue online Act for a Family Member access at any time by contacting the Health Information Management Services Department at any Medical Center in the Mid-Atlantic. For this authorization to be valid, activation of the Act for a Family Member online access feature must occur within 60 days from the date of signing this authorization form. I understand that this authorization shall be valid fora period not to exceed two (2) years. This authorization may also be revoked at anytime in writing.  \nSignature of Patient or Authorized Legal Representative Date  \nReturn completed form and supporting legal documentation (if applicable) to:  \nKaiser Permanente  \nHealth Information Management Services Department  \n*******************************************For Kaiser Permanente Internal Use Only**************************************  Approved – Diminished Capacity Patient  Not Approved – Patient does not have diminished capacity Verified by Primary Care Physician Name:  Date:  Processed by:   Date Completed:    \n00349501 (7/08)","cbCaif6I8jnc3Mrq","https://ap.wps.com/l/cbCaif6I8jnc3Mrq","pdf",1486772,"English","# Diminished Capacity Information\n## Authorization Details\n## Proxy and Legal Representative Information\n## Signing, Validity, and Revocation\n## Kaiser Permanente Internal Use","[{\"question\":\"Who can be authorized to access the patient’s protected health information?\",\"answer\":\"A patient’s designated proxy and/or legal representative can be authorized, including legal guardian, durable power of attorney for health care, or a healthcare agent.\"},{\"question\":\"What types of medical information may be released under this authorization?\",\"answer\":\"Released information may include physical and mental illness treatment, alcohol or drug abuse information, HIV/AIDS test results, HIV/AIDS diagnosis or treatment, and past medical history.\"},{\"question\":\"How long is the authorization valid and when must online access be activated?\",\"answer\":\"Online access must be activated within 60 days of signing, and the authorization remains valid for a period not to exceed two (2) years.\"}]","Act for a Family Member via Kaiser Permanente.org - Health Information Access Authorization Form | PDF",1789619102]