Kaiser permanente forms medical release forms 2003-2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the name of the health care provider and the entity or person who will receive the medical information. Fill in their title, street address, city, state, and zip code.
3. In the authorization section, specify who is authorized to release your medical information by filling in their name. Include your medical record number and date of birth for identification.
4. Indicate the duration of this authorization by entering a specific date or noting that it remains effective for one year from the date of signature.
5. Check the appropriate boxes to specify which records are to be released. Initial next to each type of information you wish to disclose, such as general medical information or specific treatment details.
6. Finally, sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship to you.

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