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Get UMC MRU00695 2016

D Rec #: Page 1 of 1 Patient’s Name: Date of Birth: SS # (optional): Street Address: City: State: Phone #: Alt. #: Zip Code: Email Address: I authorize the following facility(ies) to release my Protected Health Information (PHI) for the specified dates of service:  University Medical Center of Southern Nevada main hospital campus (UMC)  Dates of Service:  UMC Quick Care† (specify locations):  Dates of Service: †  UMC Primary Care (specify locations):  Dates.

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