Get Uc Davis Health 71431-784 2022-2025

Filling out the UC Davis Health 71431-784 form online is an essential step for individuals seeking to authorize the release of their health information. This guide provides clear instructions to help users navigate the form effortlessly and ensure that their information is processed correctly.

Follow the steps to complete the UC Davis Health 71431-784 form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editing interface.
2. Begin by entering your name in the 'Patient Name' field to provide identification.
3. Fill in your date of birth in the 'Date of Birth' section to verify your identity.
4. Enter your UC Davis Health medical record number in the corresponding field.
5. Complete your address, including city, state, and zip code, in the designated fields.
6. Provide a phone number and an email address (recommended) for any follow-up communications.
7. Specify the name of the person or facility you authorize to release your health information in the next section.
8. In the following fields, indicate the type(s) of health information you wish to release and the date range applicable.
9. Select your preferred release delivery option from the choices provided, such as US mail or electronically.
10. Review the section regarding additional protected information and select any applicable options.
11. Indicate the purpose of the release by selecting an appropriate option.
12. Complete the expiration section, ensuring to specify an expiration date or understand that it will default to 12 months after signing.
13. Sign and date the form at the end, ensuring that the signature matches the name provided.
14. If applicable, include an interpreter's signature in the provided space.
15. Finally, save your changes, download, print, or share the completed form as needed.

Complete your UC Davis Health 71431-784 form online today to ensure efficient processing of your health information.