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The form collects patient details and identifies recipient and permitted disclosures by purpose (personal use, legal, insurance, medical treatment, medical condition verification, disability, FMLA, or workers’ compensation). It lets the signer choose which Kaiser records to release (form completion substitute, last two years, or specified records) and select record types. It addresses inclusion of mental health, addiction, and HIV information, delivery media, authorization duration and revocation, and warnings about rediscLOSURE under federal privacy law, including HIPAA.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":41,"@type":70,"position":76},"https://docshare.wps.com/template/letters/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-use-or-disclosure-of-patient-health-information-hipaa/288853/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-use-or-disclosure-of-patient-health-information-hipaa/288853.png","ImageObject",442,249,{"name":88,"@type":89},"Kurz","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-11","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What can this authorization be used for?","Question",{"text":109,"@type":110},"It permits disclosure for selected purposes such as personal use, legal, insurance, medical treatment, medical condition verification, disability, FMLA, and workers’ comp.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How does the form specify which records will be released?",{"text":114,"@type":110},"It offers three options: form completion substitute, last 2 years of Kaiser records, or records as specified with required Step 1 (date range) and Step 2 (record types).",{"name":116,"@type":107,"acceptedAnswer":117},"How long is the authorization valid, and can it be canceled?",{"text":118,"@type":110},"The authorization remains in effect for one year from the signature date, with an exception in Washington, D.C. for addiction medicine records expiring after six months. It can be revoked for future releases by submitting a written request to the Release of Information Unit listed for the region of service.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},288853,1790211559,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":40,"category_name":41,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336478945635,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","(*Kaiser Permanente entities are listed on reverse side of this form)  \nAUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION  \nNote: Fees may apply to certain requests  \n( )  \nPatient Name:   Medical Record number:   Birth Date:   Address:   City:   State:   Zip Code:   Phone \\#:   Email:    \nKaiser Permanente may release this information to: q Check if same as above  \nRecipient Name:   Address:   City:   State:   Zip Code:   Phone \\#   Email:    \n( )  \nThis disclosure can be used for the following purpose(s): q Personal Use q Legal q Insurance q Medical Treatment q Medical Condition Verification q Disability q FMLA q Workers’ Comp  \nCheck ONLY one of the following three options to identify the health information to be released.  \nq Option 1: Form Completion (a substitute form or relevant medical records may be released)  \nq Option 2: Last 2 years of Kaiser Permanente Medical Office and Kaiser Foundation Hospital records  \nq Option 3: Records as specified. You must complete Step 1 and Step 2 below.  \nStep 1. Enter date range or date(s) of the records to be released:   Step 2. Select types of records to be released:  \nq KP Medical Office q Kaiser Foundation Hospital q Immunization q Lab Results  \nq Diagnostic Images q Copays & Deductibles q Itemized Billing q Pharmacy  \nq Other (provider, department, specialty):    \n| NOTE: Hospital and Medical Office records released as part of this authorization may contain references related to mental health, addiction, and HIV medical conditions. |\n| --- |\n| Check the boxes below if you want this release to include the following information, Otherwise, this information will be excluded.\u003Cbr>q Mental Health Treatment Records q Addiction Medicine Treatment Records q HIV Test Results |\n\nMedia Type: q Electronic q Paper Delivery Preference: q Electronic q Mail q Pickup  \nDURATION: Authorization shall remain in effect for one year from the date of signature below. However, in Washington, D.C. permission to release addiction medicine treatment records expires after six (6) months. 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 on the reverse side of this form. 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.  \nKaiser 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.  \nDate Signature If personal representative, print name/relationship  \nNS-9934 (9-15) SPANISH-NS-1614; CHINESE-NS-6274  \nNCAL: 90258 (REV. 9-15) SPANISH 01782-000; CHINESE 01782-002  \nORIGINAL-DISCLOSING PARTY CANARY-PATIENT  \n“Kaiser Permanente” means both your insurance company (a Kaiser Permanente health plan) and your doctors (a Permanente medical or dental group) . It also  \nincludes different groups depending on where you live.  \nAll states where we do business:  \n• Kaiser Foundation Hospitals  \nCalifornia:  \n• Kaiser Foundation Health Plan, Inc. , Northern California Region  \n• The Permanente Medical Group  \n• Kaiser Foundation Health Plan, Inc. , Southern California Region  \n• Southern California Permanente Medical Group  \nColorado:  \n• Kaiser Foundation Health Plan of Colorado  \n• Colorado Permanente Medical Group, P.C.  \nGeorgia:  \n• Kaiser Foundation Health Plan of Georgia, Inc.  \n• The Southeast Permanente Medical Group, ","cbCaifjTj0s5kFR2","https://ap.wps.com/l/cbCaifjTj0s5kFR2","pdf",197374,"English","# Authorization for Use or Disclosure\n## Patient and Recipient Information\n## Purpose and Released Record Options\n## Record Types, Media, Duration, Revocation, and Redisclosure","[{\"question\":\"What can this authorization be used for?\",\"answer\":\"It permits disclosure for selected purposes such as personal use, legal, insurance, medical treatment, medical condition verification, disability, FMLA, and workers’ comp.\"},{\"question\":\"How does the form specify which records will be released?\",\"answer\":\"It offers three options: form completion substitute, last 2 years of Kaiser records, or records as specified with required Step 1 (date range) and Step 2 (record types).\"},{\"question\":\"How long is the authorization valid, and can it be canceled?\",\"answer\":\"The authorization remains in effect for one year from the signature date, with an exception in Washington, D.C. for addiction medicine records expiring after six months. It can be revoked for future releases by submitting a written request to the Release of Information Unit listed for the region of service.\"}]","AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION - HIPAA | PDF",1789634104]