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Services and Forms Processing

We release medical information and/or help with forms that need to be completed by your physician.
All services, forms processing, and disability claim forms (except for EDD/PFL) require completion of an authorization form.

Copies of Medical Records:

  1. To receive a copy of your own records, please email or fax a Patient Authorization form to Department 160.
  2. To allow someone else (Family Member, Doctor, Attorney, or a Company) to receive a copy of your record, please email or fax a HIPPA Authorization form (Spanish version) to Department 160

To see a sample of how to fill out the authorization forms, click Release of Medical Information FAQ.

Medical Leave

  1. If you are or will be going on medical leave, please ask your doctor for a Work Status Form letter. This is your doctor’s approval note.
  2. Submit any disability form that needs to be completed by your doctor and your Work Status Form to Department 160. Make sure to fill out and attach a HIPPA Authorization (Spanish version) for each request.

To see a list of frequently asked Medical Leave questions, please click Medical Leave FAQ.

Misc. Forms (Travel Cancellation, DMV, Immunization and Nursing Home) 

  1. For any non-disability related forms, please fill out a HIPPA Authorization (Spanish version), attach it with your form, and submit e-mail or fax it to Department 160

If you have any questions or need further assistance, please e-mail us at Santa.Clara.Roi.Dept@kp.org

Santa Clara

Medical Center