Get Ucla Medical Release Form

The Ucla Medical Release Form is an essential document that allows users to authorize the release of their health information to designated individuals or facilities. This guide will provide a clear step-by-step approach to filling out the form online, ensuring that all necessary information is provided accurately.

Follow the steps to complete the Ucla Medical Release Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Fill in the first section with the name of the person or facility you are authorizing to release health information. Make sure to include their full name and any specific title if known.
3. In the next field, specify the name of the person or facility that will receive the health information. Include the complete address, including street, city, state, and zip code.
4. Select the specific healthcare facility from which you are requesting health information, such as Westwood UCLA Medical Center or any specific clinic listed in the form.
5. Indicate the type of records you wish to be released by checking the relevant boxes. Options include medical records, mental health information, laboratory reports, and more. Be sure to add any specific requests in the 'Other' section.
6. Specify the date or time period for which the information is requested. This can be a specific date or a range of time, as needed.
7. Initial the section confirming your understanding that this authorization is voluntary and that you have the right to revoke it at any time by providing written notice.
8. In the purpose of this release section, check one or more boxes to indicate why you are requesting this information, providing additional details if necessary.
9. Sign and date the form, ensuring that your printed name, phone number, and relationship to the patient, if applicable, are included. A witness or interpreter is only needed if the patient is unable to sign.
10. Once all sections are completed, save the changes made to the form. You can download, print, or share the completed document as needed.

Complete your documents online today for a hassle-free experience.