Authorization to release copies of a medical record - University 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, maiden name or AKA, date of birth, address, and contact details.
3. In the section for authorization, specify the doctor or clinic from which you are requesting records. Fill in their name and address accurately.
4. Indicate where you want the information sent by filling out the UMHS Doctor/Clinic/Unit details, including attention name and contact information.
5. Select the specific information needed by checking the appropriate boxes for records such as inpatient records, outpatient records, or lab test results.
6. State the purpose of the release/disclosure clearly in the provided section.
7. Set an expiration date for this authorization if desired; otherwise, it will automatically expire six months after signing.
8. Finally, sign and date the form at the bottom. If applicable, include details about your relationship to the patient if you are signing on their behalf.

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