Get La Lc-um2500-e 2019-2025

Filling out the LA LC-UM2500-E form can be a straightforward process when you understand the required information and steps. This guide will provide you with clear instructions on how to accurately complete the form online.

Follow the steps to efficiently complete the form.

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin by entering the patient’s information in the designated fields, including first name, middle initial, last name, and date of birth. Be sure to format the date as MM/DD/YYYY.
3. Input the patient's street address, city, state, home phone number, and optional email address. If applicable, include the cell phone number.
4. Select one of the options to authorize: either University Medical Center New Orleans, UMC Clinics, or a physician. Fill in the name of the clinic or physician as specified.
5. In the section titled 'Health Information to be used and/or disclosed under this authorization,' specify the dates of service, including start and end date. Check all relevant medical records that are to be shared.
6. Read the information about additional sensitive health information and initial to give permission for the release of specific information, if applicable.
7. Choose the purpose of the information disclosure by checking one of the options listed.
8. Provide your signature or that of a legal representative, along with the date and printed name of the patient or representative. Indicate the relationship to the patient.
9. Once completed, the form can be saved, downloaded, or printed. If needed, follow the instructions to submit the completed form to the Health Information Management Department via the preferred method (mail, fax, or email).

Complete your documentation online today to ensure your health information is handled promptly and accurately.