Get Uc Health Authorization For Release Of Patient Protected Health Information 2014-2025

Filling out the UC Health Authorization For Release Of Patient Protected Health Information form online is a crucial step in ensuring your health information is shared correctly and securely. This guide will walk you through each section of the form to help you complete it accurately.

Follow the steps to fill out the authorization form online.

1. Press the ‘Get Form’ button to access the form and open it in your designated online forms editor.
2. Begin by filling in the patient information section. Input the last name, first name, middle name, date of birth, maiden name, and the last four digits of the Social Security number. Also provide the address, city, state, and zip code, along with the phone number.
3. In the 'Copies sent to' section, indicate the agency or hospital name and the name of the person authorized to receive the information. Enter their title, street address, city, state, and zip code.
4. Next, proceed to the 'Protected health information to be used or disclosed' section. Here, check the appropriate boxes to indicate which types of health information may be shared, such as inpatient records, emergency department visits, or outpatient information.
5. Specify the reason for your request in the 'Reason needed' section. Select from the options provided, such as medical care, insurance, or legal reasons, and add any additional specified reasons in the space provided.
6. Read and understand the statements regarding the potential for re-disclosure of your protected health information and your right to revoke this authorization. Complete the section by inserting the name and address where written revocations must be sent.
7. In the 'Expiration' section, indicate when the authorization will expire or use the default expiration of 60 days.
8. Finally, you must sign and date the authorization. If you are signing on behalf of the patient, please provide your legal representative details and the scope of your authority.
9. After completing the form, ensure that you save your changes. You can choose to download, print, or share the completed form as needed.

Take action now and start filling out your documents online for easier management and access.