Get Umhs 70-10015 2021-2025

Filling out the UMHS 70-10015 form online is a straightforward process that allows you to request your medical records effectively. This guide will provide a detailed walkthrough of each section of the form to ensure your request is complete and accurate.

Follow the steps to efficiently complete the form online.

1. Click 'Get Form' button to obtain the form and open it in the editor.
2. Begin by entering your personal information. Fill in your name, maiden name or alias, date of birth, street address, optional medical record number (MRN), city/state/zip code, telephone number, and email address.
3. Indicate whether you are requesting your own medical information by selecting the appropriate option. Confirm your identity by checking the box stating you are either the patient or legally authorized representative.
4. Choose your preferred delivery method for receiving the medical records. Options include electronic delivery via the patient portal, US Mail, or other specified methods.
5. If you are requesting records to be sent to another individual or organization, provide the necessary details such as the recipient's name, company/organization name, street address, city/state/zip, and telephone number. Also, select the desired delivery method for the records.
6. State the purpose of the release by selecting the reason for disclosure from the list provided. You may also specify any additional records needed.
7. Select the specific packages of records you request and indicate any ranges of dates related to that information.
8. Indicate the expiration of the authorization by specifying a date or noting that it expires 60 days from the date signed.
9. Review the revocation policy, ensuring you understand that you can revoke authorization at any time in writing.
10. In the final section, verify the signature and printed name of the patient or their representative, including the relationship to the patient if applicable.
11. Once you have completed all sections of the form, make sure to save changes, download, print, or share the form as needed.

Complete your requests for medical records online for efficient processing.