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KAISER PERMANENTE Kaiser Foundation Hospital Southern California Permanente Medical Group AUTHORIZATION FOR RELEASE AND / OR DISCLOSURE OF MEDICAL INFORMATION IMPRINT KAISER PERMANENTE ID CARD HERE Treatment payment enrollment or eligibility for benefits will not be conditioned on my providing or refusing to provide this authorization. Please REQUEST Medical Information FROM Please SEND Medical Information TO Name of Health Care Provider Name of Person or Entity to Receive Information Name of...
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Kaiser Medical Records Fax Number
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