Authorization to Use and/or Disclose Protected Health Information - COAuthForm

Sep 17, 2026

Upload by Fez

Authorization form for Stapleton Support Services to permit Kaiser Foundation Health Plan of Colorado (KFHP) and/or Colorado Permanente Medical Group (CPMG) to release an individual’s protected health information to a designated person or organization. It collects patient identity, record type and date ranges, purpose of disclosure, and requested delivery format (paper or electronic). It includes expiration terms, revocation rights, confidentiality and re-disclosure risks, and fee/financial responsibility details for copying and shipping.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Authorization to Use and/or Disclose Protected Health Information

Patient and Disclosure Details

Purpose of Use or Disclosure

Type and Amount of Information

Requested Format for Records

Expiration, Revocation, and Confidentiality

Fees/Financial Responsibility

Office Use Only

Stapleton Support Services 11000 E. 45th Avenue, Denver, CO 80239-3004 TTY: 1-800-659-2656 Authorization to Use and/or Disclose Protected Health Information Forms Processing • Phone: 303-404-4600 Release of Information • Phone: 303-404-4700 • Fax: 303-404-4650 • Fax: 303-404-4750 I authorize Kaiser Foundation Health Plan of Colorado (KFHP) and/or the Colorado Permanente Medical Group (CPMG) to release the health information of the individual named below: Patient Name Medical Record Number Street Address City State ZIP Phone number Date ofbirth I authorize the information to be disclosed to and used by the following individual or organization: Pick up in person Fax (for forms processing only) _____Name___rec__ng________rty or org__za__on___________________ Mail Street address City State ZIP Phone number Fax number Purpose of Use or Disclosure FMLA/LOA Narrative Employer Request Personal Use Continuity of Care Return to Work Insurance Social Security Attorney Workers Compensation Other (Specify): The type and amount of information to be disclosed is as follows (specify dates): Immunizations Laboratory Results: / / to / / Most recent (years) of record X-Ray Reports: / / to / ____ Entire medical record Genetic testing: / / to / / _____ _____ FMLA/Return to work paperwork HIV/AIDS information: / / to / / Other (Specify): I am requesting that Kaiser Permanente release these records in the following format: Paper format Electronic format (only applies to records maintained by Kaiser Permanente in an electronic medical record) Page 1 of 2 CONFIDENTIAL July 2010 ______________________________________________________ Stapleton Support Services 11000 E. 45th Avenue, Denver, CO 80239-3004 TTY: 1-800-659-2656 Patient Name (please print) Medical Record Number 􀁸 I understand that the medical information released by this authorization may include information concerning treatment of physical or mental illness, alcohol/drug abuse, and past medical history. 􀁸 I understand this authorization will expire, without my expressed revocation, either one year from the date of signing, or the date the minor child becomes an adult according to state law, whichever occurs first. I understand that I may revoke this authorization by sending a request in writing to the address atthe top of this form, except to the extent that action has been taken based on it. I understand that revocation will not apply to information that has already been released as specific by this authorization or to my insurance company when the law provides my insurer with the right to contest a claim under my policy or the policy itself. 􀁸 I understand that Kaiser Permanente will only release requested records up to the date of my signature, and does not include future records. If I request to have records disclosed in the future, I will be required to complete a new authorization. 􀁸 I understand that authorization for the disclosure of this health information is voluntary and I can refuse to sign this authorization. KFHP/CPMG cannot condition treatment, payment, or enrollment in the health plan or eligibility for benefits on the signing of an authorization, except as otherwise permitted by law. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure by the receiving party, which may not be protected by federal confidentiality rules. Signature of Patient or Authorized Personal Representative Date Personal Representative’s Name and Relationship (please attach applicable legal documentation of authority) Fees/Financial responsibility: Paper Format: 􀁸 Per Colorado Department of Public Health and Environment (CDPHE) regulations, the fee for copying requested documents is $14.00 for the first ten pages, $.50 per page for pages 11 through 40, and $.33 per page for each page over 40. Shipping and applicable sale

FAQs

Who can receive the patient’s health information under this authorization?

The authorization permits KFHP and/or CPMG to release the patient’s health information to the named individual or organization listed on the form, including options such as picking up in person or receiving by mail.

What types of information can be requested for disclosure?

The form allows specifying the type and amount of information, such as immunizations, laboratory results, X-ray reports, entire medical record, genetic testing, and categories like HIV/AIDS or other specified information.

How does the authorization expire and can it be revoked?

The authorization expires, without expressed revocation, either one year after signing or when the minor child becomes an adult under state law, whichever occurs first. Revocation can be requested in writing, except to the extent actions were already taken based on the authorization.

Sep 17, 2026

Upload by Fez