Get Unc Medical Center Mim 739 Form

The UNC Medical Center MIM 739 form is an essential document for patient photograph and video information release authorization. Filling out this form accurately is important to ensure that the consent for use of images and related information is properly documented.

Follow the steps to complete the form online:

1. Press the ‘Get Form’ button to acquire the form and open it in your preferred online editing tool.
2. Begin by filling out the patient’s name in the designated field, ensuring that it is spelled correctly.
3. Indicate which uses you authorize by checking the appropriate boxes for public relations, medical purposes, or educational purposes. You may select multiple options.
4. If applicable, provide specific applications under the 'Other' section to specify any additional intended uses of the photographs or videos.
5. Read the information release section carefully. Decide whether to consent to the use of your name and indicate your choice by selecting the appropriate option.
6. In the next section, provide any additional information you authorize to be shared about yourself, your medical condition, or your treatment.
7. Complete the expiration section indicating an expiration date or condition for this authorization to remain valid.
8. Sign the form by providing your signature, printed name, and the date and time it is completed. If you are signing on behalf of the patient, ensure to document your authority.
9. If needed, a witness should also sign and date the form in the area provided.
10. Once all fields are completed, make sure to save your changes. You can then download, print, or share the completed form as needed.

Complete your documents online for a seamless experience.