303 404 4750-2026

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4.5 out of 5

35 votes

The document is an authorization form from Stapleton Support Services allowing Kaiser Foundation Health Plan of Colorado and Colorado Permanente Medical Group to release a patient's protected health information. It includes sections for patient details, recipient information, purpose of disclosure, types of information requested, and financial responsibility for copying fees. The form emphasizes the voluntary nature of the authorization and outlines the conditions under which it can be revoked.

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Click ‘Get Form’ to open the 303 404 4750 in the editor.
Begin by entering the patient’s name and medical record number in the designated fields. Ensure accuracy as this information is crucial for identification.
Fill in the patient's address, phone number, and date of birth. This data helps in verifying the identity of the individual requesting information.
Specify who will receive the health information by selecting options such as 'Pick up in person', 'Fax', or 'Mail'. Provide the name and contact details of the receiving party.
Indicate the purpose of disclosure by checking relevant boxes like 'FMLA/LOA' or 'Personal Use'. This clarifies why you are requesting this information.
Detail what specific health information you wish to disclose, including dates and types of records such as immunizations or lab results.
Choose your preferred format for receiving records: either paper or electronic. Make sure to understand any associated fees listed on the form.
Finally, sign and date the authorization at the bottom of the form. If applicable, include your personal representative's name and relationship.

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2010	4.5 Satisfied (35 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the fastest way to get medical records?

If your provider has a designated medical records department, contact them directly. Provide any reference numbers, confirmations, or details you received when submitting your request. It will help your provider quickly locate your file.

What is the health record number?

A medical record number (MRN) is a unique identifier assigned to a patient in an electronic health record (EHR), practice management, or healthcare IT system.

What is the easiest way to obtain medical records?

Check their website: Information about how to get your health record may be found under the Contact Us section of a providers website. It may direct you to an online portal, a phone number, an email address, or a form. Phone or visit: You can also call or visit your provider and ask them how to get your health record.

How long does it take to get full access to medical records?

Youre entitled to receive a response from the healthcare provider no later than 28 days after they have received your request.

Is Kaiser medical record Number the same as member ID?

The MRN enables medical records/history to be tracked for all periods of enrollment. Note: The MRN should be used as the Member ID when submitting bills or encounter data.

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What is the best way to docHub Kaiser?

Contact us Kaiser Permanente Member Services. 800-777-7902 (toll free) or TTY 711. Kaiser Permanente Medicare Member Services. 888-777-5536 (toll free) or TTY 711. Advice Line. Talk with a licensed care clinician day or night for advice, appointment scheduling, and more at no cost.