Get Uh-4948 Breleaseb Of Patient - University Bhospitalb

Filling out the UH-4948 Release of Patient form is a necessary step to authorize University Hospital to disclose your medical records. This user-friendly guide will walk you through each component of the form to ensure the process is as straightforward as possible.

Follow the steps to complete the form accurately.

1. Click ‘Get Form’ button to retrieve the form and open it in the designated editor.
2. Begin by entering the patient's name in the designated field, followed by their birthdate and social security number. Ensure all details are accurate and clearly printed.
3. In the next section, specify the name and address of the person or institution to whom the medical records will be disclosed. Input this information carefully to avoid any delays.
4. Detail the specific portion(s) of the medical records you wish to have disclosed. Include treatment dates, location of treatment, and mention any types of records to be excluded if applicable.
5. Select the purpose for the disclosure by checking the appropriate box. Options include medical care, legal purposes, insurance, or other. If you select 'Other', please specify the reason.
6. Read and acknowledge the statements regarding the potential release of sensitive information. If applicable, indicate if your medical records may contain DNA test results or genetic information.
7. Indicate the method to revoke this authorization if needed, by sending written notice, and specify the expiration date or event for this authorization.
8. Understand that signing this authorization does not affect your treatment or payment decisions by University Hospital.
9. Review the note regarding potential charges for copies of medical records, which are typically $1.00 per page.
10. Lastly, provide the signature of the patient or their legal guardian, date it, and fill in the relationship if not the patient.
11. Once completed, ensure to save changes, download, print, or share the form as needed. Mail the completed form to the address provided at the top.

Complete your authorization for the release of patient records online today to ensure timely access to your medical information.