Request for medical information for disability income - UCSB Human ... - hr ucsb 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the MEMBER INFORMATION section. Enter the patient's name, birthdate, patient number (if applicable), and social security number accurately.
3. In the NOTICE TO THE MEMBER/PATIENT section, ensure you understand that this form must be submitted to your treatment provider along with a signed Consent for Disclosure form (UCRS 158).
4. Ask your physician or treatment provider to complete their section. They will need to provide details about the patient's last visit, current symptoms, and prognosis.
5. Review each question carefully, especially regarding physical and mental impairments. Ensure all fields are filled out completely to avoid delays.
6. Once completed, save your document and send it to UC RASC—Disability Unit at the provided address.

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