Statement of authorized representative SAR form

STATEMENT OF AUTHORIZED REPRESENTATIVE – Page 1 of 2
I understand that Kaiser Permanente will not condition treatment, payment, enrollment, or eligibility
for benefits on my providing or refusing to provide this authorization.
PART A: If you wish to give authority to another party to file a complaint, grievance, Medicare Review,
or an appeal on your behalf, please complete the following information. If you wish this person to receive
Protected Health Information (PHI) regarding your treatment and care, you must check the appropriate
box(es) and you and your representative must both sign and date this form. Please return the
completed form to the requester who is handling your case.
Your Name and Address
Daytime Phone #
Alternate Phone #
Medical Record #
Medicare #
PART B: I hereby authorize the person named below to represent me regarding concerns with the quality of
care or service I have received that are provided through my employer group coverage that is administered by
Kaiser Permanente Insurance Company (KPIC). I understand that this authorization is voluntary and, if I choose to
do so, I have the right to revoke it in writing to KPIC and to my designated representative. KPIC and my designated
representative will no longer use or disclose my PHI, except to the extent KPIC or my designated representative
has taken action in reliance upon this authorization.
Name of Designated Person
Address
City
State
Daytime Phone #
(
)
ZIP Code
Evening Phone #
(
)
 I authorize Kaiser Permanente Insurance Company to disclose Protected Health Information regarding my
medical condition and care and/or payment information to the above named individual. This information must
be relevant to the request filed with KPIC on ________________________ (date of request).
SPECIFY Check the box and initial to specify which type of authorization is to be disclosed:
RECORDS: MEDICAL INFORMATION_______
INITIAL
 DRUG/ALCOHOL INFORMATION
_______________________ ___________
SIGNATURE
DATE
 PSYCHIATRIC INFORMATION
_______________________ ___________
SIGNATURE
DATE
 RESULTS OF AN HIV BLOOD TEST
_______________________ ___________
SIGNATURE
DATE
 OTHER HEALTH INFORMATION (specify below)
Specify the records to be disclosed:______________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
 This authorization shall become effective immediately and shall remain in effect until the earlier or
final resolution of my request or ____________________________(specify date).
STATEMENT OF AUTHORIZED REPRESENTATIVE – Page 2 of 2
REVOCATION: This Authorization is also subject to written revocation by the insured/patient at any
time. The written revocation will be effective upon receipt, except to the extent that the disclosing
party or others have acted in reliance upon this Authorization.
REDISCLOSURE: I understand that the recipient may not lawfully further use or disclose the health
Information unless another authorization is obtained from make or unless such use or disclosure is
specifically required or permitted by law.
Your Signature:________________________________________ Date:_____________________
PART C:
I am authorized to sign this authorization on behalf of _______________________________ and on the basis of:
 Legal Authority (Power of Attorney, etc.)
 Written Designation by Insured/Patient
 Parent, Guardian, or other individual acting in loco parentis
Authorized Representative:________________________________________ Date:_____________________
Patient has a right to a copy of this form.