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Group and group number: This is the name and ID number of your employer. (You will see this if you get your plan through work.)
This is a guidebook for people with disabilities and seniors who have Medi-Cal. This guidebook explains the two kinds of Medi-Cal: Regular Medi-Cal and Medi-Cal Health Plans.
This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan (your health insurance carrier or HMO) to release your protected health information to a person or organization that you choose.
❖ Kaiser Permanente is an HMO D-SNP plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in Kaiser Permanente depends on contract renewal.
​​Call the Medi-Nurse Line: (877) 409-9052​​
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Kaiser Permanente HMO (California) - Group #7145 (Northern CA), Group #230178 (Southern CA)
0:36 1:48 Learn How to Fill the Authorization Form - YouTube YouTube Start of suggested clip End of suggested clip Include his or her name address and the office for which the candidate is nominated. Again the dateMoreInclude his or her name address and the office for which the candidate is nominated. Again the date must be provided. And the signatures of the to authorizing. Members the President and Secretary.
Talk with a licensed care clinician day or night for advice. How to get care: Call 24/7 at 1-833-574-2273 (TTY 711).
Content for a valid authorization includes: The name of the person or entity authorized to make the request (usually the patient) The complete name of the person or entity to receive the protected health information (PHI) A specific description of the information to be used or disclosed, including the dates of service.
If you are not happy with your medical plan, you can choose another medical plan, if available. To change your medical plan, call Health Care Options at 1-800-430-4263 (TTY 1-800-430-7077). Or you can complete a Medi-Cal Choice Form. You can find the form on the Download forms page.

kaiser hipaa authorization