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UCRS 158 - UCSB Human Resources - hr ucsb 2026
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- Click ‘Get Form’ to open the UCRS 158 document in the editor.
- Begin by filling out Section A, providing your name and the names of any physicians or healthcare providers from whom you are requesting information.
- In Section B, specify the details of the healthcare provider, including their name and address. Ensure that you include your full name, including any former names, for accurate identification.
- Review the list of records you authorize for disclosure. Initial next to any specific types of records that should not be released unless explicitly authorized.
- Complete Section C by indicating the purpose of this authorization, which is to evaluate eligibility for Disability Income benefits.
- Sign and date the form in Section H. If applicable, indicate your relationship if signing on behalf of someone else.
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| 2013 | 4.8 Satisfied (165 Votes) |
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