Get University Of California Irvine Health 81610 2022-2025

Filling out the University Of California Irvine Health 81610 form for the release of health information is essential for managing your medical records. This guide provides clear, step-by-step instructions to assist users in completing the form online with confidence.

Follow the steps to effectively complete the form online:

1. Click ‘Get Form’ button to obtain the form and open it in the editing tool.
2. Fill in your personal information in the 'Patient Information' section, including your name, address, phone number, city, state, zip code, and date of birth (MMDDYYYY). It is important to provide accurate details to ensure your records are correctly identified.
3. Indicate the UCI Health facility from which you are requesting the records by selecting the appropriate options like UCI Neuropsychiatric Facility or others as applicable.
4. Provide the last four digits of your Social Security Number (SS#) to help with the identification process.
5. In the 'Release Records to' section, specify the name of the hospital, clinic, or person to whom you are authorizing the release of your protected health information (PHI). Fill in their address, city, state, zip code, fax number, and phone number.
6. Supply your email address if you wish to receive a status update regarding your request. This is important for keeping track of your records.
7. If you would like someone to pick up your records, fill in the designee's information and their relationship to you. Remember that they must present valid photo identification.
8. Choose your preferred delivery method for the records. Options include CD, paper copy, or email (note that not all facilities may send records via email). If left blank, a CD will be provided by default.
9. State the purpose for the release of information, selecting from the provided options or specifying another reason if necessary.
10. Indicate the types of records being requested by selecting the relevant checkboxes, such as emergency reports, consultations, or pathology reports.
11. For sensitive information, check the appropriate boxes and specify the date or time period for the requested information.
12. Sign the authorization form, providing your printed name, relationship (if applicable), and contact information. If someone is signing on your behalf, ensure the relationship to you is clearly stated. A witness or interpreter signature is required only if you are unable to sign.
13. Review the entire form for accuracy before submitting it. You can save all changes, download a copy, print the document, or share it as required.

Complete your authorization form online today to manage your health records efficiently.