Follow the steps to complete the form accurately and efficiently.

1. Click the ‘Get Form’ button to access the UCLA Health Form 11726 and open it in the online editor.
2. Begin filling out the form by entering your medical record number (MRN) and full patient name in the designated fields.
3. Provide your address, including street, city, state, and zip code, along with your date of birth.
4. Input your phone number and email address to ensure that UCLA Health can contact you regarding your request.
5. Specify what protected health information you would like to change by providing a detailed explanation and reasons for your request. Include the date of admission or treatment if known.
6. If your request pertains to billing or coding issues, please check the provided box to indicate this.
7. List any individuals who should receive the amended information if your request is approved. Use the provided fields for names, addresses, emails, and phone numbers.
8. If someone other than the patient is signing the form, provide their signature along with the relationship to the patient, and include the interpreter's signature and ID number if applicable.
9. Finally, review all entered information for accuracy. Once confirmed, save your changes, then you can print, download, or share the completed form as necessary.

Complete your document online today and ensure your health information is accurately represented.