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It collects patient identity, record type and date ranges, purpose of disclosure, and requested delivery format (paper or electronic). 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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.  \n􀁸 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.  \n􀁸 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.  \n Signature of Patient or Authorized Personal Representative Date  \nPersonal Representative’s Name and Relationship (please attach applicable legal documentation of authority)  \nFees/Financial responsibility:  \nPaper Format:  \n􀁸 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","cbCaibit3oZDBQgN","https://ap.wps.com/l/cbCaibit3oZDBQgN","pdf",29826,"English","# Authorization to Use and/or Disclose Protected Health Information\n## Patient and Disclosure Details\n## Purpose of Use or Disclosure\n## Type and Amount of Information\n## Requested Format for Records\n## Expiration, Revocation, and Confidentiality\n## Fees/Financial Responsibility\n## Office Use Only","[{\"question\":\"Who can receive the patient’s health information under this authorization?\",\"answer\":\"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.\"},{\"question\":\"What types of information can be requested for disclosure?\",\"answer\":\"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.\"},{\"question\":\"How does the authorization expire and can it be revoked?\",\"answer\":\"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.\"}]","Authorization to Use and/or Disclose Protected Health Information - COAuthForm | PDF",1789634104]