Get Umc Records Release Form - University Medical Center - The ... - Umc Ua

Filling out the UMC Records Release Form is an important process for anyone seeking to authorize the use or disclosure of their protected health information. This guide will provide clear, step-by-step instructions to help you complete the form effectively and ensure that your health information is handled securely.

Follow the steps to successfully complete the UMC Records Release Form.

1. Click the ‘Get Form’ button to obtain the UMC Records Release Form, and open it in your preferred editing tool.
2. Enter the patient name in the designated field to identify the individual whose health information is being released.
3. Fill in the patient’s social security number (SSN) in the appropriate section, ensuring accuracy to maintain privacy.
4. Input the chart number, which is crucial for UMC to locate the patient’s medical records efficiently.
5. Provide the patient’s date of birth in the specified format, which helps verify the identity of the patient.
6. List the persons or organizations that will be providing the information in the respective fields. Be sure to include all relevant parties.
7. Indicate the persons or organizations that will be receiving the information. Ensure that you specify each entity clearly.
8. Write a detailed description of the specific information being released, including relevant dates, to clarify the scope of the disclosure.
9. Check the appropriate boxes regarding how the information should be released (mail, telephone, fax, email, etc.). This ensures the preferred method of communication is used.
10. State the purpose for the use or disclosure of the information. If relevant, include whether it is at the request of the individual.
11. Specify the expiration date or event for the authorization, making sure it complies with UMC guidelines.
12. Read and initial all necessary statements regarding the revocation of the authorization and conditions for treatment or payment.
13. Have the patient or their representative sign and print their name clearly in the designated fields, along with the relationship or authority to act for the patient.
14. After completing the form, save your changes, and choose to download, print, or share the form as needed.

Complete your UMC Records Release Form online today to ensure your health information is managed according to your preferences.