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Kaiser permanente health plans around the country: Kaiser foundation health plan, inc. , in northern and southern california and hawaii • kaiser foundation health plan of colorado •. Check only one of the following three options to identify the health information to be released.
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Form completion (a substitute form or relevant medical records may be released). Kaiser permanente will not condition treatment, payment, enrollment or eligibility for benefits on providing, or refusing to provide this authorization. Hospital and medical ofice records. Form completion (a substitute form or relevant medical records may be released) option 2:
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Last 2 years of kaiser permanente medml office and kaiser foundation hospital. Order an electronic copy of your detailed medical records. A pdf summary of your online health records, including allergies, immunizations, ongoing health conditions, medications, test. A written request to the release of information unit listed for your region of service on the reverse side of this form. Your cancellation will not affect information that was released prior to receipt.
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