Medical Forms, Records, and Certifications

If you need a copy of your medical record for yourself or those you care for, or to share with another health care provider, you can:

• Download a summary copy that includes allergies, immunizations, ongoing health conditions, medications, test results, and some procedures. Download your health summary. 
• Request to have a detailed copy sent to you through secure email within 5 days or less. Request your medical record.

Contact the ROI Department in your area if you have questions or need help.

ROI will assist your doctor in completing your medical forms. Reach out to us directly to submit your request. Generally, a physical exam is required within the past 12 months. Some of the common medical forms that we can assist with:

• Health verification forms
• Daycare, school, sports, and camp entry forms

For school/camp entry and sports forms, most camps and schools require children to have a well-check appointment (physical exam) within the past 12 months by the time of sport/camp participation. To schedule a well-check appointment for your child, visit our online appointment center.

• DMV placard
• Medical clearance forms
• Utility baseline, like Southern California Edison
• Jury duty
• Employer forms
• Travel or accident Insurance medical certification forms
• All other types of medical forms

ROI doesn't need the hard (paper) copy of the form. We may substitute an equivalent electronic copy that meets the needs of your request. The completed forms are returned to you by email to review and make a copy for your records before you give them to your school, employer, or other organization.

Contact the ROI Department in your area to submit your request.

ROI will assist your doctor with completing a California State Disability Insurance (SDI) certification.

Before contacting ROI, follow these steps:

1. Discuss your disability and medical needs with your doctor, including your condition, the time you'll be off work, and job functions you're unable to perform. You'll need them to provide you with a work status report for the time you'll be off work. They may ask you to schedule an appointment with them.
2. Complete the one-time online registration form with the Employment Development Department (EDD).
3. File an online disability insurance claim with the EDD.
4. Keep a copy of your receipt number that displays once your claim has been submitted. 

Once your claim has been submitted online with the EDD, complete the SDI medical certification request so we can ensure your doctor has the documentation needed to process your certification. If you're requesting SDI for pregnancy or postpartum leave, you'll receive your work status report after your 32-week appointment. The work status report will be available on kp.org under "medical records" and then "letters."

When will my pregnancy and postpartum leave start?

For typical and uncomplicated pregnancies, your leave can start at 36 weeks of pregnancy. If you have certain pregnancy complications, your clinician may adjust the start of your leave. If you prefer to work past 36 weeks of pregnancy, you can’t “save” those weeks of pregnancy leave and add them to the postpartum leave after your baby arrives.

What kinds of leave can I take before and after my baby is born?

If you work in California, you may be eligible for partial wage replacement through California State Disability Insurance (SDI) and Paid Family Leave (PFL). You may also be able to request unpaid job protection through the Family Medical Leave Act (FMLA)/California Family Rights Act (CFRA).

It’s important to discuss your leave with your employer so you know which benefits you’re eligible to receive.

• California State Disability Insurance (SDI) partial wage replacement during pregnancy and the postpartum period. Your leave can start at 36 weeks of pregnancy and will continue for 6 weeks after a vaginal birth, or 8 weeks after a C-section.
• Paid Family Leave (PFL) provides partial wage replacement for up to 8 additional weeks after your SDI ends for baby bonding. It can be taken right after SDI or at any time during your baby’s first year.
• FMLA/CFRA provides up to 12 weeks of unpaid, job-protected leave.
• Private disability insurance or other benefits may be offered by your employer.

Do I need my clinician to fill out a form?

You’ll need a work status report (also called the physician/practitioner’s certification) to get your SDI benefits, pregnancy related FMLA/CFRA, or private disability insurance through your employer. You won’t need a work status report for FMLA/CFRA or PFL related to baby bonding after the birth. You’ll only need to provide proof of birth such as a birth note, birth certificate, or discharge summary. If you have pregnancy complications, you may need an updated work status report.

How do I get the work status report (physician/practitioner’s certification)?

It will be available in your medical record. This typically happens after your 32-week appointment. Let us know if you need it sooner. Go to your kp.org account and select “Medical Records” and then “Letters.”

How do I submit it to SDI?

Follow these steps:

1. Complete a one-time online registration with the Employment Development Department (EDD).
2. Submit an online disability insurance claim with the EDD. Keep a copy of the receipt number once your claim has been submitted,. You will need to provide it to Kaiser Permanente Release of Information (ROI) Department staff when requesting an SDI work status report or physician’s certification.
3. Complete the SDI medical certification request

What if I need other forms signed?

If you need other forms signed, contact your local Kaiser Permanente Release of Information Department (ROI). Don’t give forms directly to your clinician. Local ROI office phone numbers and email addresses can be found at kp.org/requestrecords. Standard forms for employers will be provided.

When can the other parent or guardian take employment leave for baby bonding?

If eligible, the other parent or guardian can take paid leave through PFL, and/or unpaid leave through FMLA/CFRA. They’ll need to submit a birth note, birth certificate, or discharge summary. They don’t need a work status report/physician’s certification from your clinician. If there’s a complication during pregnancy or delivery and you’re unable to care for yourself on your own, you may request a caregiver report from your clinician. You may share this report with any of your designated caregivers to assist with their leave requests.

What if I have more questions?

The Kaiser Permanente Release of Information Department (ROI) is here to help. ROI can assist with pregnancy verification letters, employer/private insurance forms, medical certification documents, applying for state benefits, and questions regarding pregnancy and postpartum leave. You can also contact your local ROI Department by phone or email for assistance.

Disclaimer

If you have an emergency medical condition, call 911 or go to the nearest hospital. An emergency medical condition is any of the following: (1) a medical condition that manifests itself by acute symptoms of sufficient severity (including severe pain) such that you could reasonably expect the absence of immediate medical attention to result in serious jeopardy to your health or body functions or organs; (2) active labor when there isn't enough time for safe transfer to a Plan hospital (or designated hospital) before delivery, or if transfer poses a threat to your (or your unborn child's) health and safety, or (3) a mental disorder that manifests itself by acute symptoms of sufficient severity such that either you are an immediate danger to yourself or others, or you are not immediately able to provide for, or use, food, shelter, or clothing, due to the mental disorder. This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.

ROI assists your doctor with completing a Family Medical Leave Act (FMLA) certification request for a serious or chronic (ongoing) health condition. You'll need this information when submitting your FMLA request:

• Time frame. A series of a minimum of 4 consecutive calendar days of leave or chronic intermittent leave periods such as 4 hours per week or 1 day per month or a follow up treatment schedule of leave.
• A work status report is not required for chronic condition leave (i.e., intermittent leave).
• A work status report is required for a series of consecutive days of leave (block leave). To obtain this, you'll need to discuss your disability needs with your doctor, including information about your condition, the time you'll be off work, and job functions you're unable to perform. They may ask you to schedule an appointment with them.
• Name of your employer

If this request is for someone providing care for you, we'll need their name and their employer's name.

If you're taking FMLA during or after pregnancy, learn more about this process.

Request a FMLA medical certification.

ROI can assist your doctor with completing an Attending Physician Statement for disability insurance or employer benefit submissions.

Before contacting ROI, discuss your disability needs with your doctor. You'll need them to provide you with a work status report for the time you'll be off work. They may ask you to schedule an appointment with them.

Once your doctor has provided the work status report, contact us to request an Attending Physician Statement to submit to your insurer.

Contact the ROI Department in your area if you have questions or need help.

ROI can assist your doctor with completing a Physician Certification for Reasonable Accommodation Considerations under the Americans with Disabilities Act (ADA).

Before contacting ROI, discuss your activity restrictions or impairments with your doctor and let them know that you need them to document a work and activity restriction form. They may ask you to schedule an appointment with them.

Once your doctor has documented your activity restrictions, contact us to request a Reasonable Accommodation Physician Certification.

Contact the ROI Department in your area if you have questions or need help.

You can download or print a copy of you or your child's immunization record which can be used for school, camp, an employer or for other needs.

If you haven't already, you'll need to set up caregiver access to view or download your child's record.

Download immunization records.

You can access your prescription claims and billing history online.

Prescription claims

You can view and print your Kaiser Permanente pharmacy claims and copayment history for tax purposes at Medimpact.

You can also view additional information about your prescriptions online at kp.org pharmacy.

Billing history

Access your billing records at kp.org costs and coverage. In addition to the self-service option online, contact us with the following requests: For itemized statements or patient payment or copay requests, call Member Services Contact Center at 1-800-464-4000
For Secondary insurance and supplemental billing requests, Patient Financial Services:

• HMO (KP Classics) call  1-800-498-2748
• DHMO Members and Other Payors call 1-800-390-3507

Track your requests for Medical Records, Family Medical Leave Act (FMLA) Medical Certification, and State Disability Insurance (SDI) certification requests

California law gives patients the right to have an addendum or an amendment to their medical record.  Submit an Amendment request to strike out information, delete information or append information to your medical record.  Please note that providers may deny a request to amend a patient’s medical record.  Patient must indicate whether they want to have an addendum added to their medical record or are requesting that their record be amended, or both.