UCMC-218 AUTHORIZATION FOR RELEASE OF PATIENT PROTECTED HEALTH INFORMATION.indd 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the 'Patient Information' section. Enter your last name, first name, middle name, address, city, state, zip code, date of birth, maiden name, and the last four digits of your Social Security number.
3. In the 'Copies Sent To' section, provide the agency or hospital's name and the contact person's title. Fill in their street address, city, state, and zip code.
4. Next, indicate which protected health information (PHI) you wish to be disclosed by checking the appropriate boxes under 'Protected Health Information to be Used or Disclosed'.
5. Specify the reason for your request in the 'Reason Needed' section by selecting one of the options provided.
6. Review the authorization statement carefully. Ensure you understand your rights regarding revocation and expiration before signing.
7. Finally, sign and date the form at the bottom. If applicable, include details about your legal representative's authority.

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