United Community Health Center-Maria Auxiliadora, Inc 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'To' and 'From' sections. Specify the facility name and address for both parties involved.
3. Enter your personal information in the 'Patient Information' section, including your name, date of birth, mailing address, and phone numbers.
4. Indicate the dates for which records are being requested by filling in the 'From' and 'To' fields.
5. Select the type of records you wish to request by checking the appropriate boxes under 'Records Being Requested'.
6. If applicable, initial next to any specific types of sensitive information you authorize for release.
7. Choose how you would like to receive your records by selecting an option under 'Delivery of Records'.
8. Sign and date the form at the bottom. If someone else is signing on your behalf, ensure they complete their details as well.

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