Medical Record Number: Patient Name ... - radonc.ucla.edu - radonc ucla 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Medical Record Number and Patient Name at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Fill in the Birth Date and last four digits of the SSN. This information helps verify your identity and is necessary for processing your request.
4. In the section labeled 'I authorize', specify the name of the person or facility that will release your Protected Health Information (PHI).
5. Indicate whether you would like a PAPER copy or an ELECTRONIC copy (CD) of your records.
6. Select the healthcare facility from which you are requesting PHI, such as Ronald Reagan UCLA Medical Center or others listed.
7. Check off the types of records you wish to receive, including medical, mental health, and specific documents like discharge summaries or lab reports.
8. Specify any date/time period for which you want information released.
9. Indicate the purpose of this release by checking one or more options provided on the form.
10. Finally, sign and date the authorization at the bottom of the form. If someone else is signing on your behalf, ensure they indicate their relationship to you.

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