Other Forms and Authorizations

If you have a form described here, it needs to be completed by your clinician.

Do not send these forms to the Release of Information department as that will delay your request.

A visit may be required for the items below depending upon your request. Please email your clinical team via kp.org for further instructions. You can also find their phone number by calling 503-813-2000, or 800-813-2000 or via kp.org to call them for further instructions.

Request types include but are not limited to:

  • Seniors and Caregivers – Adult Day Services, Assisted Living Facility (ALF) Orders, Death Certificate, Hospice, Independent Senior Housing, Senior Nursing Facility, SilverSneakers and/or Silver & Fit
  • Child or Dependent Care – Adoption, Children with Disabilities, Headstart, School-related Treatment Plans
  • Health Status Statements – Job Corps, Jury Duty, Plasma Donations, Hunting/Fishing
  • Physical Care and Support - PGE Medical Emergency Certification, Pet Accommodations, Trimet Disabled Rider, Non-Kaiser Permanente Dental Medical Clearance

 

Complete the following:

— Please email your clinical team via kp.org for further instructions on your specific form request. You can also find their phone number by calling 503-813-2000 or 800-813-2000 or via kp.org to call them for further instructions.
— Do not send these forms to the Release of Information department as that will delay your request.

Records to support managing care and treatment that you may want included in your medical record need to be sent to:
Kaiser Permanente Medical Records
10220 SE Sunnyside Road
Clackamas, OR 97015

These records may include but are not limited to:

  • Medical Records from Non-Kaiser Permanente Clinicians or Health Care providers
  • Advance Directives

Still have questions?
If you have additional questions, click here to contact the Release of Information department for additional assistance.

Authorizations for Sharing Protected Health Information