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The form includes required signature and date sections for mental health, alcohol/drug, and HIV test results, plus duration, revocation, and redisclosure notices under HIPAA.",{"@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/authorization-for-use-or-disclosure-of-patient-health-information-kpic-2015-ada/283775/",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/authorization-for-use-or-disclosure-of-patient-health-information-kpic-2015-ada/283775.png","ImageObject",442,249,{"name":42,"@type":43},"Stanley","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",8,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What does this authorization allow providers and recipients to do?","Question",{"text":63,"@type":64},"It authorizes named providers to produce and disclose specified copies of the patient’s medical records to the named recipient for the purposes listed in the form.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Can the patient choose which types of health information are disclosed?",{"text":68,"@type":64},"Yes. The form requires specifying the health information needed, including record types and date ranges, and it includes separate signature requirements for mental health, alcohol/drug, and HIV test results if selected.",{"name":70,"@type":61,"acceptedAnswer":71},"How long is the authorization valid, and can it be revoked?",{"text":72,"@type":64},"The authorization remains in effect for one year from the signature date unless another date is specified. The patient (or representative) can revoke it by written request, and redisclosure by the recipient may no longer be protected under federal privacy law (HIPAA).","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},283775,1789619059,{"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":80,"read_time":4},2336477405376,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0",",BJTFS 1FSNBOFOUF *OTVSBODF $PNQBOZ  \nAUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION  \nNote: Fees may apply to certain requests  \nPatient Name:   Kaiser \\#   Date of Birth:   Address:   City:   State:   Zip Code:   Telephone Number:  ( )  Email:    \nProviders named herein will not condition treatment, payment, enrollment or eligibility for benefits on providing, or refusing to provide this authorization.  \n\n| This authorizes the following Providers including Kaiser\u003Cbr>\u003Cbr>Permanente Medical Center(s):  \u003Cbr>____________________________________________\u003Cbr>To:  Produce a copy of medical records as speciſed beloY\u003Cbr>􀂉 Complete form(s) (Please specify form type(s) in the P 74 P1SE section beloY)\u003Cbr>􀂉 AlloY named physician to XieY records | \u003Cbr>Provider(s) may disclose this information to:\u003Cbr>Recipient Name:   Address:   City:  _ State:   Zip Code:   Telephone number:  ( ) (aZ number:  ( )  Email:   |\n| --- | --- |\n| P 74 P1SE: The health information disclosed may only be used for the folloY inI purposes:  |  |\n|  |  |\n\nFOR COPIES, SPECIFY THE HEALTH INFORMATION NEEDED FOR USE OR DISCLOSURE  \n􀂉 /edical 1fſce 4ecords dated from   to    \n􀂉 Hospital Records dated from   to    \nNOTE􀀜 HQURKVCN CPF OGFKECN QHſEG TGEQTFU OC[ KPENWFG KPHQTOCVKQP TGNCVGF VQ OGPVCN JGCNVJ, alcohol/drug, and HIV references. The actual treatment records from mental health and/or alcohol/drug deRartments, and/or results of HIV tests YK ll not De dKsclosed unless sRecKſcall[ reSuested DeloY.  \n\n| SIGNATURES AND DATES REQUIRED IF ANY OF THE FOLLOWING BOXES ARE CHECKED |\n| --- |\n| \u003Cbr>􀂉 Mental Health dated from   to   SiInature:   Date: \u003Cbr>􀂉 Alcohol 􀀑 DruI dated from   to   SiInature:   Date: \u003Cbr>􀂉 HIV Test Results dated from   to   SiInature:   Date:  |\n\n􀂉 Speciſc InLury􀀑Treatment:   Department:   dated from   to    \n􀂉 X-Ray: 􀂉 ImaIes and􀀑or (ilms 􀂉 Reports Describe:    \n􀂉 Laboratory Results dated from   to    \n􀂉 Other (specify):    \n􀂉 Protected Minor Records (Adolescent Conſdential) 􀀐 Only applicable for patient reSuesters 􀀓􀀔-􀀓􀀙 years old 􀀐  \nMedia Preference: 􀂉Paper 􀂉CD (if aXailable electronically) DeliXer[ Preference: 􀂉Mail 􀂉PicMup 􀂉 (aZ 􀂉Email  \nDURATION: This authori\\ation shall remain in effect for one year from the date of siInature unless a different date is speciſed here   (date) 􀀐  \nREVOCATION: ;ou or your representatiXe can reXoMe this authori\\ation upon Yritten reSuest 􀀐 If youreXoMe􀀎 it Y ill not affect information disclosed before the receipt of the Y ritten reSuest 􀀐  \nREDISCLOSURE: Once this health information is disclosed 􀀎 hoY the recipient further discloses it may no lonIer be protected under federal priXacy laY (HIPAA) 􀀐  \nA copy of this authori\\ation is as Xalid as an oriIinal 􀀐 I haXe the riIht to receiXe a copy of this authori\\ation 􀀐  \nDate SiInature If not patient􀀎 print your name and relationship  \nKP-KPIC-HIPAA AUTHORIZATION 12012015","cbCaivyGhRX0dZkY","https://ap.wps.com/l/cbCaivyGhRX0dZkY","pdf",276303,"English","# Authorization Details\n## Providers and Recipient Information\n## Purpose and Permitted Use\n## Requested Health Information\n## Signatures and Dates\n## Duration, Revocation, and Redisclosure","[{\"question\":\"What does this authorization allow providers and recipients to do?\",\"answer\":\"It authorizes named providers to produce and disclose specified copies of the patient’s medical records to the named recipient for the purposes listed in the form.\"},{\"question\":\"Can the patient choose which types of health information are disclosed?\",\"answer\":\"Yes. The form requires specifying the health information needed, including record types and date ranges, and it includes separate signature requirements for mental health, alcohol/drug, and HIV test results if selected.\"},{\"question\":\"How long is the authorization valid, and can it be revoked?\",\"answer\":\"The authorization remains in effect for one year from the signature date unless another date is specified. The patient (or representative) can revoke it by written request, and redisclosure by the recipient may no longer be protected under federal privacy law (HIPAA).\"}]","Authorization for Use or Disclosure of Patient Health Information - KPIC 2015 ADA | PDF"]