HIPAA Authorization for the Use or Disclosure of Health Information from Kaiser Permanente

Completion of this document authorizes the use and disclosure of health information about you. Failure to provide all information requested may invalidate this Authorization.

I understand that Kaiser Permanente* is required to maintain and safeguard the privacy and security of my information under applicable federal, state and local health information privacy rules that govern the use and disclosure of my information, including but not limited to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), as amended from time to time.

By agreeing to this HIPAA Authorization, I hereby authorize Kaiser Permanente to use and disclose within and among the Kaiser Permanente entities (see below), such as my regional health plan and regional Permanente Medical Group, and to other third parties as specified for the purposes listed below, the contact information that I have provided to kp.org (my name, mailing and email addresses, telephone number and, as appropriate, Social Security Number) so that Kaiser Permanente may use and disclose my information for the following purposes:

As required by applicable law, this Authorization lasts for a year unless I revoke it.

I understand that I have the right to revoke this Authorization, at any time by navigating to Profile and Preferences, Data Sharing & Authorizations on the kp.org website or Profile & Settings, Data Sharing & Authorizations on the KP Mobile Application and following the instructions provided. Kaiser Permanente will stop using or disclosing my information for these purposes upon Kaiser Permanente’s receipt of my revocation. However, my revocation will not be effective with respect to actions Kaiser Permanente took in reliance upon my Authorization.

I understand that once information is used or disclosed under this Authorization, there is a potential for it to be redisclosed and may no longer be protected under federal or state privacy law. However, state law may prohibit the person receiving my information from making future disclosures of my information unless another authorization for disclosure is obtained from me, or unless such disclosure is specifically required or permitted by law.

I understand that I have a right to receive a copy of this Authorization by navigating to the kp.org website or KP Mobile Application and scrolling to the bottom of the home page and selecting the HIPAA Authorization link to obtain a copy.

Kaiser Permanente will not condition my treatment, payment or eligibility for benefits on whether I agree to this Authorization electronically or on paper. I have read the above information and authorize the use and disclosure of my information by Kaiser Permanente for the purposes described herein.

*For purposes of this HIPAA Authorization, “Kaiser Permanente” means:

Kaiser Foundation Health Plan, Inc.; Northern California Region
The Permanente Medical Group

Kaiser Foundation Health Plan, Inc.; Southern California Region
Southern California Permanente Medical Group

Kaiser Foundation Health Plan of Colorado
Colorado Permanente Medical Group

Kaiser Foundation Health Plan of Georgia
The Southeast Permanente Medical Group

Kaiser Foundation Health Plan, Inc.; Hawai‘i Region
Hawai‘i Permanente Medical Group

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
Mid-Atlantic Permanente Group, P.C.

Kaiser Foundation Health Plan of the Northwest
Northwest Permanente Medical Group

Kaiser Foundation Health Plan of Washington
Washington Permanente Medical Group

Kaiser Foundation Health Plan of Washington Options, Inc.

Kaiser Foundation Hospitals

Last updated: October 2022

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