Get Mrn: Patient Name: Authorization For Release Of Protected Health Information (phi ...

Filling out the Authorization for Release of Protected Health Information (PHI) form online is an essential step for individuals wanting to manage their medical records. This guide provides clear, step-by-step instructions to ensure accurate and efficient completion of the form.

Follow the steps to fill out the Authorization for Release of Protected Health Information (PHI) form online

1. Click 'Get Form' button to obtain the form and open it in your preferred editor.
2. In the Patient Information section, fill in your name, medical record number (MRN), address, city, state, zip code, date of birth, and phone number.
3. Specify the healthcare facility from which you want to release records. Select from options like UCLA Health Hospitals/Clinics, Jules Stein Eye Institute, or Resnick Neuropsychiatric Hospital.
4. In the 'Release Records To' section, provide the name of the hospital, clinic, or person to whom you want to send your health information. Don't forget to include their address and phone number.
5. If you want to set a designee to pick up your records, fill in the name and relationship of the individual indicating their responsibilities.
6. Choose your preferred delivery method for the records by checking the appropriate box: CD, email, or paper copy.
7. State the purpose of the release by checking the corresponding box. You can specify 'at the request of the patient/patient representative' or provide another reason.
8. Indicate the type of records you are requesting by checking all applicable boxes. This includes options such as billing statements, emergency reports, lab reports, and more.
9. If your request includes sensitive information, ensure to check the relevant boxes and specify the date/time period for the requested sensitive data.
10. Complete the expiration date section for the authorization, or it will automatically expire 12 months after signing.
11. Sign and date the authorization. If a legal representative is signing, ensure their relationship to the patient is indicated.
12. If needed, have a witness or interpreter sign where required.
13. Finally, save your changes, and download or print the form for your records before submitting it according to the instructions.

Take control of your health information: complete your Authorization for Release of Protected Health Information (PHI) form online today.