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Release of Medical Records FAQs

What form do I fill out to get a personal copy of my medical records?
Complete the Patient Authorization Form

What form do I fill out for someone else to get a copy of my medical records? (friend, family member, doctor, attorney, insurance company, and etc..)
Complete the HIPPA Authorization form (Spanish version)

Where do I send my authorization request?
You may fax it to 877-627-8407, email it to santa.clara.roi.dept@kp.org, or drop off at Dept. 160

Is there a fee to request for medical records?
It depends…

  • For patient request - last 2 years of records emailed or burned on CD is FREE

  • For paper copies - $.25 per page

  • For Portable Electronic Medical Record (Flash Drive - contains short summary of records) - $5

  • Any xray images CD/DVD (all requesters) - $15

Please email ROI for more information on all other fees not mentioned above.

I am continuing my care with a different hospital, I don’t know which records and how much records I need to transfer to my new hospital.
You may fill out a Kaiser HIPPA Authorization and request for the Last 2 Years of your medical records to be transferred over. If your new doctor decides to ask for more, have him/her request from Kaiser directly.

I am a new member and I want to transfer my outside records to my new Kaiser Doctor, how may I do this?
You need to sign a release from your old doctor and address your records to be sent to your new Kaiser Doctor…example:

Kaiser Permanente
ATTN: Dr. Bob Joe (Department 123)
710 Lawrence Expressway
Santa Clara, CA 95051

Where do I submit a form request asking for my child’s information? (i.e. School Forms, Immunizations, Camp)
If your child is still under Pediatric care, you may submit it to Pediatrics Department 186

What's required to pick up requests for someone else?
A signed and dated permission letter by the member stating who will be picking up on their behalf.

What's required to drop off requests for someone else?
A signed authorization by the member and a copy of their Government ID (Driver’s License, Passport, or Identification Card)

What form do I need other than the HIPPA Authorization if I am signing for a patient who is deceased/incapacitated physically and/or mentally?
(POA) "power of attorney" or advanced health care directive with the requestors name on it as the primary agent. If the primary agent is unavailable, he or she must provide the requestor a signed and dated permission letter to request on his or her behalf or a death certificate indicating requestor as an immediate family member (husband, wife, son, or daughter)

My question is still not answered, what is the quickest way to receive an answer from your department?
To receive a quick response, please email any medical records related questions and or authorization requests to santa.clara.roi.dept@kp.org - Provide your first & last name, date of birth, and your Kaiser Medical Number (or Social Security) to receive the most accurate information.

Santa Clara

Medical Center