AUTHORIZATION FOR RELEASE OF (PHI - UCLA Health - uclahealth: Fill out & sign online

Here's how it works

01. Edit your form online

Type text, add images, blackout confidential details, add comments, highlights and more.

02. Sign it in a few clicks

Draw your signature, type it, upload its image, or use your mobile device as a signature pad.

03. Share your form with others

Send it via email, link, or fax. You can also download it, export it or print it out.

How to use or fill out AUTHORIZATION FOR RELEASE OF (PHI - UCLA Health - uclahealth

Ease of Setup

DocHub User Ratings on G2

Ease of Use

DocHub User Ratings on G2

Click ‘Get Form’ to open it in the editor.
Begin by entering your Medical Record Number, Patient Name, Birth Date, and the last four digits of your SSN in the designated fields.
In the 'I authorize' section, specify the name of the person or facility that will release your PHI.
Fill in the name and address of the person or facility receiving your PHI. Choose whether you want a PAPER copy or an ELECTRONIC copy.
Select the healthcare facility from which you are requesting PHI by checking one of the options provided.
Indicate the type of records you wish to obtain by checking all relevant boxes under 'TYPE OF RECORDS'.
Specify any date or time period for which you are requesting information.
Check one or more reasons for this release under 'THE PURPOSE OF THIS RELEASE IS'.
Sign and date at the bottom of the form, ensuring all required fields are completed before submission.

Start using our platform today to easily complete your AUTHORIZATION FOR RELEASE OF (PHI) form for free!

See more AUTHORIZATION FOR RELEASE OF (PHI - UCLA Health - uclahealth versions

We've got more versions of the AUTHORIZATION FOR RELEASE OF (PHI - UCLA Health - uclahealth form. Select the right AUTHORIZATION FOR RELEASE OF (PHI - UCLA Health - uclahealth version from the list and start editing it straight away!

Versions	Form popularity	Fillable & printable
2021	4.2 Satisfied (32 Votes)
2019	4.8 Satisfied (211 Votes)
2016	4.4 Satisfied (38 Votes)
2014	3.9 Satisfied (32 Votes)
2012	4.4 Satisfied (167 Votes)
2008	4.8 Satisfied (40 Votes)

be ready to get more

Complete this form in 5 minutes or less

Get form

Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Contact us

What is the authorization for the release of protected health information in California?

(a) Patients may authorize the release of their health care information by completing the CDCR 7385, Authorization for Release of Protected Health Information , to allow a family member or friend to request and receive an update when there is a significant change in the patient s health care condition.

What is an authorization for release of confidential health information?

A HIPAA release form is a document that when signed allows healthcare providers to share a patients protected health information (PHI) with specified individuals or organizations, ing to the details stipulated in the form.

What is required for releasing protected health information?

A covered entity must obtain an authorization to use or disclose protected health information for marketing, except for face-to-face marketing communications between a covered entity and an individual, and for a covered entitys provision of promotional gifts of nominal value.

Who can authorize the release of PHI?

The patient must provide the authorization of release of PHI to the covered entity. If the patient does not provide a written authorization of release of PHI, the doctor may not release the PHI even if the patient gives verbal permission.

How to fill out authorization for release of PHI?

How do I fill out a HIPAA release form? Provide instructions. Name the patient and individual authorized to use or disclose their PHI. Describe the information. Specify recipients. Specify the purpose of disclosure. Specify the time period. Detail their revocation rights. Obtain the patients signature.