Transcription of Authorization for Kaiser Permanente to Use/Disclose ...
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1. Member must complete this section PATIENT. NICKNAME / MAIDEN NAME / OTHER. HEALTH RECORD NO. Kaiser Foundation Health Plan of the Northwest Kaiser Foundation Hospitals DATE OF BIRTH (MO/DAY/YR) PHONE NUMBER. ( ). ADDRESS STREET OR BOX NUMBER. Authorization for Kaiser Permanente to CITY STATE ZIP + 4. Use/Disclose Protected Health Information 2. I authorize Kaiser Permanente to release the following information for: _____. 3. NAME OF PERSON TO RECEIVE INFORMATION. TITLE (PHYSICIAN, ATTORNEY, ETC.) PHONE NUMBER. STREET ADDRESS CITY STATE ZIP CODE. 4. The purpose or need for the exchange and disclosure of this information is to: 1) Facilitate treatment; 2) Summarize treatment and/or; 3) Facilitate billing/reimbursement from insurance carriers.
0004-1756 9/13 Privacy & Security White: OPMR – Scan Yellow - Patient Kaiser Foundation Health Plan of the Northwest • Kaiser Foundation Hospitals
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