AUTHORIZATION FOR USE AND DISCLOSURE OF
PHARMACY INFORMATION
Instructions
Patient self-request for prescription dispensing records
• Complete Authorization for Use and Disclosure of Pharmacy Information on Page 2
• Patient must date and sign the authorization form
If the request is from an individual other than patient
• Individual must date, sign, and indicate relationship to the patients on the authorization form
• Individual must also include evidence of the legal authority to act on behalf of the patient along with the form. Evidence
includes, but not limited to:
o Letters of Guardianship
o Letters of Conservatorship
o Power of Attorney
o Death Certificate
Submit completed form and fee, if applicable, by mail (fax copies not accepted) to:
Kaiser Permanente
Pharmacy Informatics
PO Box 5075
Livermore, CA 94551-5075
Third Party Requests (i.e. law firms, housing developments, etc)
• Complete Authorization for Use and Disclosure of Pharmacy Information on Page 2
• Patient must date and sign the authorization form
• Third Party must also include evidence of legal authority to act on behalf of the patient along with the form. Evidence
includes, but limited to:
o Notice that individual has retained Third Party’s services on the company letter head
Third party requests may be sent to:
Kaiser Permanente
Pharmacy Records Request Desk
12254 Bellflower Blvd
Downey, CA 90242
Subpoenas and court orders must be served in person to the Pharmacy Custodian of Records at the address listed above.
Fees:
• NCAL: Request for records up to the past 30 months is available as a courtesy. Records beyond 30 months are assessed
a service fee of $15.00 per request / per member / patient. Enclose check or Money order made to the order of: Kaiser
• SCAL: Request for records up to the past 36 months is available as a courtesy. Records beyond 36 months are assessed
a service fee of $15.00 per request / per member / patient. Enclose check or Money order made to the order of: Kaiser
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AUTHORIZATION FOR USE AND DISCLOSURE OF
PHARMACY INFORMATION
Kaiser Permanente will not condition treatment, payment, enrollment or eligibility for benefits on
providing, or refusing to provide this authorization
Patient Information:
Print Name of Patient
Address
City State Zip
Medical Record Number
Date of Birth
Email Telephone Number
I hereby authorize: Kaiser Permanente Pharmacy, and / or Kaiser Foundation Health Plan Pharmacy, and / or
Kaiser Foundation Hospital Pharmacy to disclose to:
Print Name of Recipient
Address
City State Zip
SPECIFY THE PHARMACY INFORMATION TO BE USED OR DISCLOSED (mark all that apply):
Pharmacy Records dated from _________________ to ________________
Specific Drugs(s)/Medication(s) Records: _____________________ dated from _________ to ________
Medical Expenses Detail Summary dated from _________________ to _________________
Other (specify): _______________________________________________________________________
NOTE: Pharmacy records including any information related to alcohol/drug treatment will not be
disclosed unless specifically authorized below. SIGNATURE AND DATE IS REQUIRED
IF BOX IS
CHECKED.
Alcohol / Drug dated from ________ to ________ Signature: ______________ Date: __________
Media Type: Electronic (Preferred) Paper
Delivery Preference: Email (Preferred) ____________________________ Mail
PURPOSE: The pharmacy records and information disclosed may only be used for the following purpose(s):
____________________________________________________________________________.
DURATION: This authorization shall remain in effect for one year from the date of my signature below
unless a different date is specified here ___________ (date).
REVOCATION: You or your personal representative can revoke this authorization upon written request.
If you revoke, it will not affect information disclosed before the receipt of your written request to revoke.
REDISCLOSURE: I understand that information disclosed pursuant to this authorization may no longer be
protected under federal privacy law (HIPAA) and could be re-disclosed by the recipient. However, California
A copy of this authorization is as valid as the original. I have the right to receive a copy of this authorization.
Date Signature If Signed by Other than Member/Patient, Indicate Relationship
VERIFICATION OF SIGNEE'S IDENTITY (For Internal Use Only)
Date:
The identity of the Member / Patient or Personal Representative was verified using the attached:
Driver's License Other Photo Identification Notarized Document Other
The legal authority of Personal Representative (if applicable) was verified using the attached:
Letters of Guardianship Letters of Conservatorship Power of Attorney Other
Member’s Region
Northern California
Southern California
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