Release oflnformation Unit 2026

1. Click ‘Get Form’ to open the Release of Information Unit in the editor.
2. 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.
3. Fill in your UMHS Medical Record Number (UMHSMRN), City/State/Zip, Telephone Number, and Email Address. This information helps facilitate communication.
4. 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.
5. Select the specific information needed from the list provided. If applicable, include any additional details in the 'Other' section.
6. Choose the purpose of release/disclosure by checking one or more boxes that apply to your situation.
7. Specify an expiration date for this authorization. If left blank, it will expire six months from the signature date.
8. 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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