Ucla medical release form 2026

1. Click ‘Get Form’ to open the UCLA Medical Release Form in our editor.
2. Begin by entering your Medical Record Number, Patient Name, Birth Date, and the last four digits of your SSN in the designated fields.
3. In the authorization section, specify the name of the person or facility authorized to release your Protected Health Information (PHI).
4. Next, indicate who will receive the PHI by filling in their name and address. Choose whether you want a paper copy or an electronic copy.
5. Select the healthcare facility from which you are requesting PHI. Options include Ronald Reagan UCLA Medical Center and others listed on the form.
6. Check off the types of records you wish to obtain, such as medical records or mental health information.
7. Specify any date or time period for which you are requesting information.
8. Indicate the purpose of this release by checking one or more options provided.
9. Finally, sign and date the form at the bottom. Ensure that all required fields are completed before submitting.

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