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Kaiser permanente medical records fax number southern california 2026

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The document is an authorization form from Kaiser Permanente for the release and disclosure of medical information. It outlines the process for patients to request their medical records to be sent to a specified healthcare provider or entity, including details on revocation of consent, redisclosure of information, and the types of records that can be released. The authorization remains effective until a specified date or for one year if no date is provided.

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Click ‘Get Form’ to open it in the editor.
Begin by imprinting your Kaiser Permanente ID card in the designated area at the top of the form.
Fill in the 'REQUEST Medical Information FROM' section with the name of your healthcare provider and their address.
In the 'SEND Medical Information TO' section, provide the name and address of the person or entity that will receive your medical information.
Complete the patient identification fields, including your name, address, medical record number, date of birth, and telephone number.
Specify which records you want released by checking the appropriate boxes and providing any necessary date ranges.
Sign and date the authorization at the bottom of the form. If applicable, indicate your relationship if signing on behalf of another person.

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