Medical-records-authorization-form-english-102022 2026

1. Begin by clicking ‘Get Form’ to open the medical records authorization form in our editor.
2. Fill in your personal information, including your name, address, phone number, and date of birth. Ensure accuracy as this information is crucial for identification.
3. Specify the healthcare facility from which you are requesting records. You can choose UCI Health Hospitals/Clinics or other specified facilities.
4. Indicate where you want the records sent by providing the name and address of the recipient. Include a fax number or email if applicable.
5. If someone else will pick up your records, complete the designee section with their details and relationship to you.
6. Select the delivery method for your records: CD, email (if applicable), or paper copy. Make sure to check any additional instructions provided.
7. Specify the purpose of the release and select the types of health information you wish to be released from the options provided.
8. Sign and date the form at the bottom. If someone else is signing on your behalf, indicate their relationship to you.

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