Get Uc Health Authorization For Release Of Patient Protected Health Information 2013

This guide provides clear and concise instructions on how to complete the UC Health Authorization For Release Of Patient Protected Health Information form online. It is designed to assist individuals in navigating the form effectively while ensuring that their protected health information is handled in accordance with privacy regulations.

Follow the steps to complete the authorization form accurately.

1. Press the ‘Get Form’ button to access the authorization form and open it in your document editor.
2. Fill in the patient information section accurately. This includes the last name, first name, middle name (if applicable), maiden name (if applicable), address, city, state, zip code, date of birth, social security number, and phone number.
3. In the 'Copies Sent From/To' section, indicate the agency or hospital involved in the disclosure of information. Fill in the name and title of the person responsible for handling the request, along with the address details including the street address, city, state, and zip code.
4. Specify which parts of the protected health information (PHI) you authorize to be used or disclosed by checking the appropriate boxes for inpatient, emergency department, physical therapy, same day surgery, or outpatient.
5. Provide specific dates of service for the records you need. Avoid requesting 'any and all' records to expedite the processing of your request.
6. Select the pertinent summary documents you would like to receive from the visits, such as lab reports, discharge summary, or medical history, by marking the corresponding boxes.
7. Indicate the reason for your request by checking one of the options provided, such as medical care, legal reasons, or personal reasons.
8. Read the revocation and expiration statements carefully. Understand your rights regarding the authorization and complete the expiration date or event if necessary.
9. Sign the form in the designated area and date your signature. If you are signing on behalf of the patient, provide an explanation for your authority to act and attach any necessary documentation.
10. Once all sections are completed, save your changes. You can choose to download, print, or share the completed form as needed.

Complete and submit your authorization form online to ensure your request is processed efficiently.