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If the request is made by someone other than the patient, legal documents showing authority to represent the patient are required.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},283776,1790019596,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":140,"read_time":22},5909890329169,"https://ap-avatar.wpscdn.com/davatar_9964176cb1d06d4a9deccf72a44ae3dc","HAWAII REGION  \nAuthorization for Verbal Release of Protected Health Information (PHI) Original: 5/03/07 Revised: 10/30/2025  \nMR \\#:  \nName:  \nSex/BD:  \n Use BLACK ball point pen. Format: Date: MM | DD | YY* Time: Military *Birthdays require full year ( example: 1907 instead of ‘07 )   \n1. CHECK AUTHORIZATION TYPE (one or both):  1a. Telephone Messages:  \nI hereby authorize Kaiser Permanente to leave a detailed message regarding my medical care on my voicemail, or with anyone answering the telephone.  \nKaiser will use the phone numbers currently on file for you.  \n1b. Authorized Person:  \nI hereby authorize:      \nLast Name, First Name Relationship  \nTo receive information verbally in person or via phone for:  \nPatient Name: Last:   First:   MI:    \nBirthdate:   |   |   MR \\#:    \n2. COMPLETE DISCLOSURE TYPE, SIGN AND DATE (required):  Disclosure Type:  \nVerbal disclosure is authorized for any and all information about medical history, mental and physical condition, including HIV infection, AIDs, or ARC, drug and alcohol use, and other personal information unless otherwise specified:  \n__________________________________________________________________________________________________________________  \n__________________________________________________________________________________________________________________  \nSignature:  \nI understand that I am authorizing Kaiser Permanente Hawaii to verbally release protected health information to anyone answering the telephone numbers on file, or to the authorized person, including but not limited to medical care, membership, and billing transactions.  \nI, the requester/ representative, have filled out this form completely. All blank fields are intentional. I understand that this authorization is voluntary and that Kaiser Permanente Hawaii will not condition my treatment, payment, enrollment in the health plan, or eligibility for benefits upon signing this form.  \nThis authorization is in effect until updated or revoked in writing.  \n  x     |   |    \nPrint Name Signature Date  \nIf signed by other than patient or parent of minor child, please print name below and indicate relationship. Submit documents to show authority.  \nPrint Authorized Representative’s Name Relationship to patient  \n\n| For Kaiser Use Only: Add New Update Cancel Verify full understanding and total completion of form with patient. | |\n| --- | --- |\n| Verify ID: Driver's License State ID Legal Documents Passport Other:  Is activation URGENT? No Yes Fax to Patient ID immediately: 432-5050\u003Cbr>Print delegate’s name, date, and send original form to Medical Records Administration Scanning/RHQ\u003Cbr>Patient ID: Enter in KP HealthConnect FYI “Patient Communications”KP Staff Name: (print )\u003Cbr>Name:   Loc:   Dept:   Phone \\#:   -   |  |\n\n1026 9083 10/2025 White-Send to Medical Records Administration Scanning/RHQ Canary-KP Delegate Pink-Patient Copy  \n PATIENT INSTRUCTIONS   \n1. This form must be completed by the requester in person at a Kaiser Permanente patient service facility. If information is incomplete, the request may be rejected, requiring the requester to complete another form in person.  \n2. This form must be submitted to Kaiser Permanente staff. A valid picture ID is required for verification at the time of submittal. If this communication request is made by persons other than the patient, legal documentation proving your identity and legal authority to represent the patient is required ( e.g. legal or other notarized documents ) .  \n3. Please allow 3 business days ( m-f ) from the day of receipt, for this request to become effective. If needed immediately, please inform Kaiser Permanente staff. Every reasonable effort will be made to process the request in a timely manner.  \n VERBAL RELEASE GUIDELINES   \n1. Telephone messaging is NOT for emergencies! Telephone messaging is not appropriate for urgent or emergent situations.  \n2. No one can guarantee the security and privacy of telephone messages.  \n3. To update the ph","cbCaisIx8Qi9wvtB","https://ap.wps.com/l/cbCaisIx8Qi9wvtB","pdf",919357,"English","# Authorization for Verbal Release of Protected Health Information (PHI)\n## Authorization type (telephone messages and/or authorized person)\n## Disclosure type, signature, and effective period\n## Patient instructions and verbal release guidelines","[{\"question\":\"What information can be released verbally under this PHI authorization?\",\"answer\":\"Verbal disclosure is authorized for any and all information about medical history and physical or mental condition, including sensitive categories like HIV infection and drug or alcohol use, unless otherwise specified in the disclosure section.\"},{\"question\":\"How long is the authorization valid and can it be changed?\",\"answer\":\"The authorization remains in effect until updated or revoked in writing.\"},{\"question\":\"What identification and submission requirements apply when submitting this form?\",\"answer\":\"The form must be completed in person at a Kaiser Permanente patient service facility and submitted to Kaiser Permanente staff with a valid picture ID for verification. If the request is made by someone other than the patient, legal documents showing authority to represent the patient are required.\"}]","Hawaii Region - Authorization for Verbal Release of Protected Health Information (PHI) | PDF",1789619090]