UCRS 158 - UCSB Human Resources - hr ucsb 2026

1. Click ‘Get Form’ to open the UCRS 158 document in the editor.
2. Begin by filling out Section A, providing your name and the names of any physicians or healthcare providers from whom you are requesting information.
3. 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.
4. 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.
5. Complete Section C by indicating the purpose of this authorization, which is to evaluate eligibility for Disability Income benefits.
6. Sign and date the form in Section H. If applicable, indicate your relationship if signing on behalf of someone else.

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