University health system form 2026

1. Click ‘Get Form’ to open the university health system form in the editor.
2. Begin by entering the patient’s name, including last, first, and middle names, along with their medical record number and date of birth.
3. Fill in the patient’s address and phone numbers. Ensure all contact information is accurate for effective communication.
4. Indicate whether you are authorizing disclosure to yourself or another designee by checking the appropriate box. If it’s a designee, provide their name and contact details.
5. Select the specific information to be disclosed by checking the relevant boxes for treatment dates and types of records needed.
6. Specify the purpose of disclosure by checking one or more options provided in the form.
7. Choose how you would like the information delivered: via mail, fax, or electronic format.
8. Sign and date the authorization at the bottom of the form. Make sure to include your relationship to the patient if applicable.

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