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The form explains what information may be disclosed, why it is needed to coordinate and integrate SUD treatment with other aspects of care, and how sharing supports medication safety, care-plan adjustments, and continuity of treatment during emergency or urgent visits. It also states consent is voluntary and outlines how to revoke authorization.",{"@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-to-share-substance-use-disorder-information-to-coordinate-your-health-care/288861/",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-to-share-substance-use-disorder-information-to-coordinate-your-health-care/288861.png","ImageObject",442,249,{"name":88,"@type":89},"Ben ","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-07","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information is Kaiser Permanente asking to share?","Question",{"text":109,"@type":110},"Kaiser Permanente’s MH/AMRS Program requests authorization to share SUD diagnosis and/or records relating to SUD treatment (“SUD Medical Information”).","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Why is this authorization needed?",{"text":114,"@type":110},"The authorization helps coordinate care and ensures important medical information is provided to the care team when necessary, including avoiding negative medication interactions and enabling treatment plan adjustments.",{"name":116,"@type":107,"acceptedAnswer":117},"Can the authorization be revoked?",{"text":118,"@type":110},"Yes. You or your personal representative may cancel future releases by submitting a written request to the Release of Medical Information Department at a Northern California Kaiser Permanente Medical Center.","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},288861,1790463936,{"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":76,"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},2336478951081,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","AUTHORIZATION TO SHARE SUBSTANCE USE DISORDER INFORMATION TO COORDINATE YOUR HEALTH CARE —  \nPage 1 of 3   \nMR\\#:    \nName:   \nIMPRINT AREA  \nKaiser Permanente operates as an integrated health care delivery system. In order for you to receive the most effective, coordinated care, it is important that members of your care team understand all aspects of your care, including treatment for a substance use disorder.  \nWhat We Are Requesting:  \nKaiser Permanente’s Mental Health and Addiction Medicine and Recovery Services Program (“MH/AMRS Program”) requests your authorization to share your substance use disorder diagnosesand/or records relating to your substance use disorder treatment (“SUD Medical Information”) with Kaiser Foundation Health Plan (“KFHP”), The Permanente Medical Group (“TPMG”), and Kaiser Foundation Hospitals (“KFH”) as necessary to coordinate and integrate your substance use disorder treatment with the rest of your care at Kaiser Permanente.  \nWhy We Are Requesting this Authorization:  \nWe are seeking this authorization to help coordinate your care and to ensure that important medical information about you is provided to your care team when necessary. The benefits of giving us this authorization include:  \n• Keeps your other providers informed of your treatment so they can ensure that there are no negative interactions with any other medications you are taking.  \n• Allows your doctors to adjust your treatment plan for other health conditions. Substance abuse disorder treatment could affect treatment options for other conditions. Unless other doctors are aware of this, they cannot adjust your individual treatment plan.  \n• Ensures you get proper treatment if you visit a Kaiser Permanente Emergency or Urgent Care Department.  \nGiving Your Authorization is Voluntary:  \nYou may either agree or refuse to authorize the release of your SUD Medical Information. Your decision about whether or not to sign this authorization is completely voluntary, and will not affect your eligibility for future care, membership in the Kaiser Foundation Health Plan, or the care you receive from your Mental Health and Addiction Medicine and Recovery Services providers.  \nYour Authorization:  \nIf you sign the authorization form and authorize us to share SUD Medical Information with other Kaiser Permanente providers, federal laws and our own privacy policies allow us to share that limited information ONLY for the purposes of coordinating your care. With your permission, we would share information with your other treating providers within the Kaiser Permanente Northern California Region.  \nIf, at any time, you have concerns about your privacy, please ask your therapist or a staff member for clarification.  \nDOCUMENT TYPE: CHEMICAL DEPENDENCY DESCRIPTION: CDS CARE COORDINATION AUTHORIZATION  \nDO NOT LINK TO ENCOUNTER DATE:    \n02150-033 (10-21) FOR SPANISH USE 02150-133, CHINESE-02150-233  \nAUTHORIZATION TO SHARE SUBSTANCE USE DISORDER INFORMATION TO COORDINATE YOUR HEALTH CARE —  \nPage 2 of 3   \nMR\\#:    \nName:   \nIMPRINT AREA  \nInstructions:  \nPlease review the information below and select only one of the following Options. Agreement to Authorize Release of Your SUD Medical Information:  \nBy filling out the authorization section below (Option A), you acknowledge that you have read and understood this document. You authorize Kaiser Permanente’s MH/AMRS Program to share your SUD Medical Information with providers within the Kaiser Permanente Northern California Region as necessary to coordinate your care. This includes, but is not limited to, notes for coordination of care, diagnoses, laboratory results, and medications.  \nOption A:  \nAgreement to Authorize Release of Your SUD Medical Information  \nI   AUTHORIZE Kaiser Permanente’s MH/AMRS Program to disclose all or any portion of my SUD Medical Information to providers within the Kaiser Permanente Northern California Region for the purpose of coordinating my health care among my treating provid","cbCaibEHqZ74TB72","https://ap.wps.com/l/cbCaibEHqZ74TB72","pdf",192644,"English","# What We Are Requesting\n# Why We Are Requesting this Authorization\n# Giving Your Authorization is Voluntary\n# Your Authorization\n# Instructions and Options\n## Option A: Agreement to Authorize Release of Your SUD Medical Information\n# Revoking Authorization","[{\"question\":\"What information is Kaiser Permanente asking to share?\",\"answer\":\"Kaiser Permanente’s MH/AMRS Program requests authorization to share SUD diagnosis and/or records relating to SUD treatment (“SUD Medical Information”).\"},{\"question\":\"Why is this authorization needed?\",\"answer\":\"The authorization helps coordinate care and ensures important medical information is provided to the care team when necessary, including avoiding negative medication interactions and enabling treatment plan adjustments.\"},{\"question\":\"Can the authorization be revoked?\",\"answer\":\"Yes. You or your personal representative may cancel future releases by submitting a written request to the Release of Medical Information Department at a Northern California Kaiser Permanente Medical Center.\"}]","AUTHORIZATION TO SHARE SUBSTANCE USE DISORDER INFORMATION TO COORDINATE YOUR HEALTH CARE | PDF",1789634111]