PDF UMHA HIPAA Privacy Consent & Auth Form - University of Maryland 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out your personal information in Section 1, including your last name, first name, member ID number, birth date, and address. Ensure all details are accurate for proper identification.
3. In Section 2, designate individuals authorized to receive your Protected Health Information (PHI). Provide their names, contact numbers, addresses, and relationship to you. Choose the appropriate level of access for each individual.
4. Review the consent terms outlined in Section 3. Your signature is required here to confirm your understanding and agreement. If applicable, check the boxes regarding minor status or legal representation.
5. Finally, complete the revocation section if you wish to retain that option. Make sure to sign and date the form before submission.

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