Kaiser permanente statement form 2026

1. Click ‘Get Form’ to open the Kaiser Permanente Statement of Authorized Representative in the editor.
2. Begin with Part A by entering your name, address, and contact numbers. Ensure that all information is accurate for effective communication.
3. In Part B, designate a representative by filling in their name and contact details. Check the appropriate boxes to authorize the disclosure of Protected Health Information (PHI) relevant to your case.
4. Specify the type of information you wish to disclose by checking the relevant boxes and providing any additional details if necessary.
5. Sign and date the form at the designated areas to validate your authorization. If applicable, complete Part C regarding your authority to sign on behalf of another individual.
6. Review all entries for accuracy before submitting. Once completed, return the form to the Member Services office handling your case.

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