KP Authorization FormAuthorization to Release Confidential Information Name * First Name Last Name I hereby authorize RADUCA KAPLAN ("Provider") to release confidential information obtained during the course of my treatment to KAISER PERMANENTE ("Recipient"). * Yes No This Authorization permits the release of the following information: Diagnosis Prognosis Treatment Plan Clinical Test Results Progress to Date Dates of Treatment Any and All Information Necessary Other Kindly specify if you checked other I authorize the release of the information described above for the following purpose(s): The specific uses and limitations on the types of information to be released are as follows: The specific uses and limitations on the use of the information by Recipient are as follows: I understand that I have a right to receive a copy of this Authorization, and that any modification or revocation of this Authorization must be in writing. * Yes No The authorization shall remain valid until ["Expiration Date"]. * MM DD YYYY I understand that the details provided above are true * Yes No Approval of Patient or Patient's Representative in the box below. * I approve I disapprove Today's Date * MM DD YYYY Thank you!
