Ucla 30910 2026

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4.8 out of 5

211 votes

The document is an 'Authorization for Release of Health Information' form from UCLA Health, allowing patients to authorize the release of their protected health information (PHI) to specified individuals or facilities. It includes sections for patient information, recipient details, types of records requested, delivery instructions, and sensitive information consent. The form emphasizes the importance of confidentiality and outlines the patient's rights regarding the authorization process.

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Click ‘Get Form’ to open the UCLA 30910 document in the editor.
Begin by entering your Patient Name and MRN at the top of the form. Ensure that this information is accurate as it identifies your medical records.
Fill in your Address, City, State & Zip Code, Date of Birth, and Phone number. This personal information is crucial for proper identification.
Specify where you want your health records sent by selecting from the options provided, such as UCLA Health Hospitals/Clinics or Jules Stein Eye Institute.
If applicable, authorize a designee to pick up your records by filling in their name and relationship to you.
Select the delivery method for your records: CD, E-Mail, Paper Copy, or Call Requestor when ready for pickup.
Indicate the purpose of this release and specify what type of health information you wish to be released by checking the appropriate boxes.
Sign and date the authorization at the bottom of the form. If someone else is signing on your behalf, indicate their relationship to you.

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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)

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