HIM19000 Authorization to Disclose Protected Health Information 2026

1. Click ‘Get Form’ to open the HIM19000 Authorization in the editor.
2. Begin by selecting the UCHealth facility or group from which you are requesting records. Check the appropriate box next to the facility name.
3. Fill in your personal information, including your name, any former names, birth date, address, and phone number.
4. Indicate the purpose of your request by checking one of the options provided, such as 'Continuation of care' or 'Personal'.
5. Specify who you authorize to receive your information by entering their name and contact details in the designated fields.
6. Provide a date range for the services you are requesting by filling in the 'From' and 'To' fields.
7. Select your preferred method of release for receiving your records, such as email or pick-up at the facility.
8. Check all types of records you wish to disclose. If applicable, consent to disclose specialized information by signing where indicated.
9. Sign and date the form at the bottom to complete your authorization.

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