[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283778-105":53,"doc-detail-283778-en":126},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":119,"head_meta":121,"extra_data":123,"updated_unix":125},105,"en","authorization-to-use-and-disclose-protected-behavioral-health-information-kaiser-permanente","Authorization to Use and Disclose Protected Behavioral Health Information - Kaiser Permanente","","Authorization form for Kaiser Permanente Behavioral Health Department to permit release of protected behavioral health information to a Primary Care Physician for coordination of care. Explains that disclosed behavioral health information may become part of the general medical record and may be subject to redisclosure. Describes protections under applicable state mental health laws and federal confidentiality rules for alcohol and drug abuse patient records, including 42 CFR Part 2, plus rights to revoke consent and related insurance validity timelines.",{"@graph":63,"@context":118},[64,80,101],{"@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":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-to-use-and-disclose-protected-behavioral-health-information-kaiser-permanente/283778/",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-use-and-disclose-protected-behavioral-health-information-kaiser-permanente/283778.png","ImageObject",442,249,{"name":88,"@type":89},"supergirl","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":20},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What is the purpose of signing this authorization?","Question",{"text":108,"@type":109},"Signing authorizes Kaiser Permanente Behavioral Health to release your behavioral health information to your Primary Care Physician so care can be coordinated.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is confidentiality protected after information is disclosed?",{"text":113,"@type":109},"The form explains that disclosed information may become part of the general medical record and could be subject to redisclosure. It also notes protections under state mental health laws and federal confidentiality rules for alcohol and drug abuse records (42 CFR Part 2).",{"name":115,"@type":106,"acceptedAnswer":116},"Can I revoke this authorization, and does it affect insurance-related validity?",{"text":117,"@type":109},"You may revoke consent at any time in writing, except to the extent action has already been taken in reliance on it. For insurance contract purposes, the authorization validity differs by whether it relates to an application/benefit claim and may automatically expire twelve months from the signed date.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},283778,1791376287,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":20,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962088121634,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","(2)the duration of the claim if the claim is not for an accident and sickness insurance benefit.  \nIAUTHORIZE:  \nKaiser PermanenteBehavioral Health Department  \nThe following portions of my Behavioral Health chart:  \n□Diagnosis  \nMRN:                                      \nPatient/Guardian:  \n(Signature)  \nAuthorization to Use and Disclose Protected Behavioral Health Information  \nIauthorize the release of my behavioral health information to my Primary Care Physician for purposes of coordinatingmy health care.I understand that as a result of this authorization,the behavioral health information disclosed pursuantto this authorization will become a part of my general medical record and thereby may be subject to redisclosure.  \nIunderstand that my Behavioral Health records are protected under the applicable state law governing health careinformation that relates to mental health services.They may also be protected under federal regulations governingConfidentiality of Alcohol and Drug Abuse Patient Records(42 CRF Part 2)  \nlalso understand that I may revoke this consent at any time (in writing)except to the extent that action has beentaken in reliance on it.To revoke this authorization,please provide a written statement to the Kaiser PermanenteBehavioral Health Department.Kaiser Permanente may not condition treatment,payment,enrollment or eligibility forbenefits on my providing or refusingto provide this authorization.FOR INSURANCE CONTRACTS ISSUED IN THECOMMONWEALTH OF VIRGINIAOR DISTRICT OF COLUMBIA:I understand that this authorization shall be valid:(a)in the case of authorizations signedfor the purpose of collecting information in connection with an application for aninsurance policy,a policy reinstatement,or a request for change in policy benefits:(1)Thirty months from the date theauthorization is signed if the application or request involves;life,accident and sickness,or disability insurance;(b)in thecase of authorizations signed for the purpose of collecting information in connection with a claim for benefits under aninsurance policy:(1)the term of coverage of the policy if the claim is for an accident and sickness insurance benefit;  \nThis authorization will automatically expire twelve months from the date signed.I may obtain a copy of this authorizationupon request.A copy of this authorization will be sent with my records to my Primary Care Physician.I also understandthat I am entitled to inspect my records.  \nTO RELEASE TO:My Primary Care Physician &Health Care TeamMid-Atlantic States Permanente Medical Group andKaiser Foundation Health Plan of the Mid-Atlantic States,Inc.  \nOr Network Provider:                                                  \nPrint Provider's Name  \n□ Chemical Dependency history &treatment Information  \n□Treatment Plan □Medication □Other                                                                \n\n| □ Iunderstand that the Behavioral Health information being released pursuant to this Authorization wil  \u003Cbr>become part of my general medical record and may be subject to redisclosure.  \u003Cbr>Date_  \u003Cbr>Signature_   |\n| --- |\n| If other than patient,indicate relationship:_   |\n\nD.O.B.:                             _  \nDate::                        \nIf other than patient,indicate relationship:_                                                            \nTO THE PERSON(S)RECEIVING RECORDS:If this authorization pertains to alcohol or drug information.please note that this information has been disclosed to you from records protected by federal confidentiality rules(42CFR part 2).Federal rules prohibit you from making any further disclosure of this information unless further disclosureis expressly permitted by written authorization of the person to whom it pertains or as otherwise permitted by 42 CFRpart 2.A general authorization for release of medical or other information is not sufficient for this purpose.Federal rulesrestrict any use of the information to criminally investigate or prosecute any alcohol or drug","cbCaik3mw7AtJbFf","https://ap.wps.com/l/cbCaik3mw7AtJbFf","pdf",254571,"English","# Why you are being asked to sign an Authorization Form\n## Purpose of the authorization\n## Confidentiality and redisclosure protections\n## Revocation, expiration, and insurance validity","[{\"question\":\"What is the purpose of signing this authorization?\",\"answer\":\"Signing authorizes Kaiser Permanente Behavioral Health to release your behavioral health information to your Primary Care Physician so care can be coordinated.\"},{\"question\":\"How is confidentiality protected after information is disclosed?\",\"answer\":\"The form explains that disclosed information may become part of the general medical record and could be subject to redisclosure. It also notes protections under state mental health laws and federal confidentiality rules for alcohol and drug abuse records (42 CFR Part 2).\"},{\"question\":\"Can I revoke this authorization, and does it affect insurance-related validity?\",\"answer\":\"You may revoke consent at any time in writing, except to the extent action has already been taken in reliance on it. For insurance contract purposes, the authorization validity differs by whether it relates to an application/benefit claim and may automatically expire twelve months from the signed date.\"}]","Authorization to Use and Disclose Protected Behavioral Health Information - Kaiser Permanente | PDF",1789619095]