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WESTSIDE PSYCHOTHERAPY, LLC 4513 Vernon Blvd, Suite 100, Madison, WI 53705 (608) 236 4460 (608) 236 4461 fax REQUEST AND AUTHORIZATION FOR RELEASE OF INFORMATION RE: Date of Birth: Address Phone #:
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01
To fill out the Kaiser Permanente Release of Information form, follow these steps:
02
Start by reading the instructions provided on the form thoroughly.
03
Provide your personal information, including your full name, address, date of birth, and contact information.
04
Indicate the specific information you want to release by checking the appropriate boxes or writing it down clearly.
05
Specify the purpose of the release and provide any additional details if necessary.
06
Review the form to ensure all the information is accurate and complete.
07
Sign and date the form at the designated section.
08
If required, provide the name and contact information of the person or organization to whom the information will be released.
09
Keep a copy of the filled-out form for your records.
10
Submit the form to the designated recipient or follow the instructions provided.

Who needs kaiser permanente release of?

01
Any individual who wishes to grant permission for Kaiser Permanente to release their medical information to another person or organization may need to fill out the Kaiser Permanente Release of Information form.
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Kaiser Permanente Release of refers to the process or document related to the release of medical information or records by Kaiser Permanente, a healthcare organization.
Individuals who wish to access their medical records or authorize the release of their medical information to third parties are required to file the Kaiser Permanente Release of.
To fill out the Kaiser Permanente Release of, individuals need to provide their personal information, specify the information to be released, state the purpose for the release, and sign the document.
The purpose of the Kaiser Permanente Release of is to authorize the sharing of a patient's medical records or information, either with another healthcare provider or for personal use.
The information that must be reported includes the patient’s full name, date of birth, the specific records requested, the purpose of the release, and the recipient’s information.
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