AUTHORIZATION TO PATIENTT INFORMATION 2026

1. Click ‘Get Form’ to open the AUTHORIZATION TO DISCLOSE OR RELEASE PROTECTED HEALTH INFORMATION in the editor.
2. Begin by filling out the Patient Information section. Enter your first name, middle initial, last name, and date of birth in the specified format (MM/DD/YYYY).
3. Provide your street address, city, state, home phone number, and optional email address. Ensure all information is accurate for effective communication.
4. Select one option for authorization: either University Medical Center New Orleans or UMC Clinics. Fill in the physician's name and clinic name as required.
5. Indicate whether you want to receive information from or release it to another party. If releasing to yourself, ensure your details are filled correctly.
6. Specify the health information to be disclosed by checking relevant boxes and providing dates of service where applicable.
7. Read through the acknowledgment of understanding section carefully before signing. This confirms your consent and understanding of the terms outlined.
8. Finally, sign and date the form at the bottom. If applicable, include any supporting documentation for a legal representative.

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