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Release oflnformation Unit 2026
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- Click ‘Get Form’ to open the Release of Information Unit in the editor.
- Begin by entering your Date of Birth, Patient Name, Maiden/AKA, and Street Address in the designated fields. Ensure all information is accurate for proper identification.
- Fill in your UMHS Medical Record Number (UMHSMRN), City/State/Zip, Telephone Number, and Email Address. This information helps facilitate communication.
- Indicate whether you are the patient or a legally authorized representative by checking the appropriate box. Then, specify the individuals or organizations authorized to receive clinical communication.
- Select the specific information needed from the list provided. If applicable, include any additional details in the 'Other' section.
- Choose the purpose of release/disclosure by checking one or more boxes that apply to your situation.
- Specify an expiration date for this authorization. If left blank, it will expire six months from the signature date.
- Sign and date the form at the bottom. If you are a legally authorized representative, include your printed name and relationship to the patient.
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Related links
The Release of Information (ROI) Office support to the WCM community on health information request, access, and disclosures. Phone: (866)-293-3077
A request to the Department of Health (Department) for medical records must be completed by submitting a valid Authorization for Release of Records form