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The authorization explains that SUD medical records are protected under federal confidentiality and Substance Use Disorder Patient Records regulations and HIPAA, and will be shared only when providers determine it is necessary. It covers what records are requested, why coordination reduces medication-interaction risks, protections for sharing within the Southern California region, potential additional risks of declining, an emergency waiver, and how to revoke consent or choose consent versus refusal options.",{"@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/authorize-the-sharing-of-substance-use-disorder-sud-medical-information-medical-information-authorization/288860/",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/authorize-the-sharing-of-substance-use-disorder-sud-medical-information-medical-information-authorization/288860.png","ImageObject",442,249,{"name":88,"@type":89},"Mary Man","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",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What does this authorization allow Kaiser Permanente to share?","Question",{"text":109,"@type":110},"It allows the Addiction Medicine Department to share records related to SUD diagnosis and treatment with other Kaiser Permanente providers in the Southern California region to coordinate and integrate your overall care.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"Why is Kaiser Permanente requesting this coordination of care?",{"text":114,"@type":110},"To help providers work together and prevent negative medication interactions and to ensure appropriate treatment, including if you visit Kaiser Permanente emergency or urgent care.",{"name":116,"@type":107,"acceptedAnswer":117},"Can I revoke or refuse this authorization?",{"text":118,"@type":110},"Yes. 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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 SUD. We will only share the SUD Medical Information that, in the professional opinion of our providers, is necessary to coordinate and integrate your healthcare as described below.  \nI understand that my SUD Medical Information records are protected under the Federal regulations governing Confidentiality and Substance Use Disorder Patient Records, 42 C. F. R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C. F. R. pts 160 & 164, and cannot be disclosed by the Program without my written consent unless otherwise provided for by the regulations.  \nWhat We Are Requesting  \nAn authorization for your Kaiser Permanente’s Addiction Medicine Department (Program) to share records related to your SUD diagnosis and treatment with your Other Kaiser Permanente Providers-which include medical providers within Southern California Permanente Medical Group (SCPMG), and Kaiser Foundation Hospitals (KFH) to insure your SUD Medical Information is considered as part of your overall medical care you receive within Kaiser Permanente.  \nWhy We Are Requesting this Coordination of Care Authorization  \nThe Program and your Other Kaiser Permanente Providers can best coordinate your overall medical care, if they can work together to prevent negative medication interactions you might experience with the prescribed medications you are taking, or with your treatment programs for other conditions or illnesses.  \nEnsures you get proper treatment if you visit a Kaiser Permanente Emergency or Urgent Care Department.  \nYour Protection: Federal laws and Kaiser Permanente’s own privacy policies allow us to share necessary information ONLY with Other Kaiser Permanente Providers within the Southern California region and ONLY for the purposes of integrating or coordinating your care. If at any time you have concerns about your privacy, please ask your therapist or a staff member for assistance in care coordination.  \nThe potential consequences (collectively, the “Additional Risks”) of declining this Care Coordination Authorization for non-Emergency Medical Care include:  \nIt is possible that dangerous, and even fatal conflicts could occur that would be avoided by integration and coordination of care. The risks of complications in your overall medical care, including chronic pain, chronic disability, disfigurement and death.  \nDS-1000 (12-19) PAGE 1 OF 4 FOR SPANISH USE DS-1001, CHINESE-DS-1002  \nAUTHORIZE THE SHARING OF SUBSTANCE USE DISORDER (SUD) MEDICAL INFORMATION  \nName:    \nMR\\#:    \nIMPRINT AREA  \nMedical Emergency Waiver  \nRegardless of whether you consent to the sharing of your SUD Medical Information with Other Kaiser Permanente Providers, your SUD Medical Information may be disclosed to medical personnel to the extent necessary to meet a bona fide medical emergency in which the patient’s prior informed consent cannot be obtained.  \nRevoking Authorization  \nYou or your personal representative may cancel this authorization by submitting a written request to the Release of Information Unit at any Southern California Region Kaiser Permanente Medical Center.  \nYour cancellation will not affect information that was released prior to receipt of the written request.  \nOnce we receive your revocation, the Program will no longer disclose any SUD Medical Information to Other Kaiser Permanente Providers, except for the information already disclosed during the time when we had your authorization or when the law allows us to disclose the SUD Information without your permission AND you assume the “Additional Ri","cbCaip1qriSbEQBQ","https://ap.wps.com/l/cbCaip1qriSbEQBQ","pdf",206549,"English","# What We Are Requesting\n# Why We Are Requesting Care Coordination\n# Your Protection\n# Medical Emergency Waiver\n# Revoking Authorization\n# Giving Authorization is Voluntary","[{\"question\":\"What does this authorization allow Kaiser Permanente to share?\",\"answer\":\"It allows the Addiction Medicine Department to share records related to SUD diagnosis and treatment with other Kaiser Permanente providers in the Southern California region to coordinate and integrate your overall care.\"},{\"question\":\"Why is Kaiser Permanente requesting this coordination of care?\",\"answer\":\"To help providers work together and prevent negative medication interactions and to ensure appropriate treatment, including if you visit Kaiser Permanente emergency or urgent care.\"},{\"question\":\"Can I revoke or refuse this authorization?\",\"answer\":\"Yes. You can cancel in writing to the Release of Information Unit. Refusing or revoking does not change prior information already released, and continuing authorization remains in effect until you are no longer covered, unless revoked.\"}]","AUTHORIZE THE SHARING OF SUBSTANCE USE DISORDER (SUD) MEDICAL INFORMATION - Medical Information Authorization | PDF",1789634111]