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Ucla medical release form 2026
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- Click ‘Get Form’ to open the UCLA Medical Release Form in our editor.
- Begin by entering your Medical Record Number, Patient Name, Birth Date, and the last four digits of your SSN in the designated fields.
- In the authorization section, specify the name of the person or facility authorized to release your Protected Health Information (PHI).
- 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.
- Select the healthcare facility from which you are requesting PHI. Options include Ronald Reagan UCLA Medical Center and others listed on the form.
- Check off the types of records you wish to obtain, such as medical records or mental health information.
- Specify any date or time period for which you are requesting information.
- Indicate the purpose of this release by checking one or more options provided.
- Finally, sign and date the form at the bottom. Ensure that all required fields are completed before submitting.
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