Ucmc 218 2025

1. Click ‘Get Form’ to open the ucmc 218 in the editor.
2. Begin by entering the patient’s name and maiden name in the designated fields. Ensure accuracy as this information is crucial for identification.
3. Fill in the address, city, state, zip code, last four digits of the Social Security number, date of birth, and telephone number. Double-check these details for correctness.
4. Select the specific facility needed from the options provided. If applicable, specify any other facility not listed.
5. Indicate the purpose of this request by checking the appropriate box. You may select multiple purposes if necessary.
6. Detail the dates of treatment and specify what type of information you wish to disclose by checking relevant boxes.
7. Provide the name and contact information of the individual or organization that will receive this health information.
8. Review your entries carefully before signing at the bottom. If signed by a legal representative, ensure they attach necessary documentation.

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