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How to fill out the UCLA 30910 online
The UCLA 30910 form is used to authorize the release of protected health information (PHI). This guide provides clear and detailed instructions on how to complete the form online, ensuring that users can navigate the process with confidence.
Follow the steps to successfully complete the UCLA 30910 form
- Press the ‘Get Form’ button to obtain the form and open it in the online editor.
- Enter your medical record number, name, birth date, and the last four digits of your Social Security number in the designated fields to help identify your medical records.
- In the section labeled 'I authorize,' write the name of the person or facility that holds your PHI.
- Provide the name and address of the person or facility to receive the PHI in the respective fields.
- Select whether you would like to request a paper copy or an electronic copy of your PHI by checking the appropriate option.
- Specify the healthcare facility from which you are requesting your PHI by selecting from the provided options or entering a clinic name.
- Indicate the type of records you wish to release by marking the relevant options pertaining to medical or mental health records.
- Detail the specific information you wish to release by checking the appropriate boxes next to the types of records listed.
- Specify the date or time period for the information requested in the designated section.
- Select the purpose of the release by checking the appropriate box or writing in your reason.
- Have the patient or a legal representative initial the form to indicate consent.
- Sign and date the authorization at the bottom of the form, ensuring to include the time of signing.
- If someone other than the patient is signing, indicate their relationship in the designated space and have a witness or interpreter sign if necessary.
- Once all sections are completed, users can save changes, download, print, or share the completed form as needed.
Complete your documentation online today and ensure a smooth release of your protected health information.
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The authorization for the release of protected health information in California is a signed document that grants healthcare providers the right to disclose medical records as specified by the patient. This authorization is vital in maintaining privacy while ensuring that vital health information can be accessed when necessary. At UCLA 30910, understanding this process is essential for protecting your rights and managing your health information efficiently.
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