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Downloading the form - UT Physicians

Downloading the form - UT Physicians 2025

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The document is an authorization form for UT Physicians patients to request the use and disclosure of their protected health information to another provider. It outlines the patient's consent for sharing specific medical records, including clinical records, lab reports, and other health-related information. The form also informs patients about potential fees, the possibility of re-disclosure by non-covered entities, and their right to revoke the authorization.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Patient’s Name, Birth date, or MRN# and Phone number in the designated fields.
Select the types of records you wish to disclose by checking the appropriate boxes, such as Complete Clinical Records or specific reports like X-ray or Laboratory test reports.
Fill in the Recipient's details if you choose to send or fax the records. Include their Name, Company, Address, and Fax Number if applicable.
Indicate the purpose of this authorization in the provided space to clarify why you are requesting these records.
Sign and date the form at the bottom. If applicable, include your printed name and authority if you are signing on behalf of someone else.

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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.

What is the fax number for University of Toledo medical records?

ELECTRONIC DELIVERY OF YOUR MEDICAL RECORDS Fax your signed copy to 419-383-3001, Once enabled, you will receive two e-mails.

How can I get a copy of my medical records in Texas?

The Department of State Health Services is committed to providing full access to public information. To request records under the Texas Public Information Act: Submit a request in writing via U.S. Mail, fax or email. Include contact information and a clear description of the records you are requesting.

What is the easiest way to request medical records?

Check their website: Information about how to get your health record may be found under the Contact Us section of a providers website. It may direct you to an online portal, a phone number, an email address, or a form. Phone or visit: You can also call or visit your provider and ask them how to get your health record.

How to send medical records via fax?

How to Fax Medical Records? Log into your eFax account online. Click Create Cover Page in the File menu and customize it with a confidentiality statement. Add your recipients and upload the medical records as documents or PDF files. Hit Send and make sure you receive a delivery confirmation notification.