Uf protected 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Patient’s Name, Date of Birth, and Medical Record # in Section 1. Ensure that you verify your identity using one of the provided options.
3. Fill in the Patient’s Address, including City, State, and Zip Code. Optionally, provide the last four digits of the SSN and Phone #.
4. If applicable, indicate if the patient is an employee by checking the corresponding box.
5. In Section 2, enter the Name of Representative and their Relationship to Patient. Provide their Address and Phone Number as well.
6. Complete Section 3 by specifying where to send the PHI. Include any necessary details about the facility or person receiving this information.
7. In Section 4, authorize the release of PHI by signing at Box 25 and dating it appropriately.

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