To help expedite your request you may fill out the form below with as much detail as possible, and identify the specific records you are requesting. Medi-Cal Rx Prior Authorization Request Form.Instructions: Fill out all applicable sections on all pages completely and legibly. Download, print and complete the authorization form. The authorization form must be signed and dated. Our Release of Information (ROI) Department helps you complete forms for disability or medical leave and provides required medical information. This California HIPAA release form enables patients to permit any person or 3rd party organization to have access to their personal health records. Submit a medical request online, or find information about how to request medical care from Kaiser Permanente. Patient Information. Patient Full Name: Date of Birth: Patient Address: Other Names?