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- Request records, forms certifications | Kaiser Permanente
The Kaiser Permanente Release of Information Department (ROI) is here to help ROI can assist with pregnancy verification letters, employer private insurance forms, medical certification documents, applying for state benefits, and questions regarding pregnancy and postpartum leave
- AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED . . . - Kaiser Permanente
Check ONLY one of the following three options to identify the health information to be released q Option 1: Form Completion (a substitute form or relevant medical records may be released) qOption 2: Last 2 years of Kaiser Permanente Medical Office and Kaiser Foundation Hospital records qOption 3: Records as specified You must complete Step 1
- Request records, forms certifications | Kaiser Permanente
Submit a medical request online, or find information about how to request medical care from Kaiser Permanente
- AUTHORIZATION FOR USE OR DISCLOSURE OF PATIENT HEALTH INFORMATION
Check the boxes below if you want this release to include the protected treating department or HIV initial test result information If not checked, this treating department information will be excluded
- Patient Name: Address City tate i Code hone ( ) - Kaiser Permanente
(*Kaiser Permanente entities are listed on reverse side of this form) ote ees may aly to certain reuests Patient Name: Medical Record number irth ate Address City tate i Code hone mail Kaiser Permanente may release this information to: q Check if same as aboe Recipient Name: _____
- Request records, forms certifications | Kaiser Permanente
To request your digital images in person, via mail, or to have them sent to a non-Kaiser Permanente provider, you must complete and sign the Authorization to Release Health Care Information form (PDF) To pick up your CD in person, you must show your driver's license or other approved photo ID
- 1. PATIENT INFORMATION - Kaiser Permanente
Fill out this form to release health care information, requesting that medical records be sent to yourself or to a non-Kaiser Permanente doctor, facility, or other party Includes instructions Keywords
- Request records, forms certifications | Kaiser Permanente
Manage Records outside of Kaiser Permanente HI Contact your Kaiser Permanente Hawaii primary care physician to send external records directly to their office Pharmacy records To request these records, you will need to fill out an authorization for release of protected health information (PHI) form (PDF) Then contact us at: Phone: (808
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