Get Ucla 30910 2014

The UCLA 30910 form is essential for authorizing the release of protected health information (PHI). This guide will provide clear and effective instructions on how to fill out this form online, ensuring you complete it accurately and efficiently.

Follow the steps to successfully fill out the UCLA 30910 form.

1. Click the ‘Get Form’ button to obtain the UCLA 30910 form and open it in your preferred online editor.
2. Enter the medical record number, patient name, birth date, and the last four digits of the social security number in the designated fields.
3. Specify the name of the person or facility authorized to release PHI, filling in the corresponding field.
4. Provide the address, city, state, and zip code of the person or facility receiving the PHI as prompted.
5. Select your preference for receiving the records by checking either the box for a paper copy or the box for an electronic copy (CD).
6. Identify the healthcare facility from which you are requesting PHI by selecting the appropriate option from the list, or specify the name of a clinic as required.
7. Indicate the type of records you wish to receive, checking all relevant options such as medical or mental health records.
8. Specify the date or time period for the requested information in the provided space.
9. Select one or more purposes for the release of information by checking the corresponding box, or provide another reason in the designated area.
10. Sign the form in the space provided, including the date and time of signature. Ensure to indicate your printed name and, if applicable, your relationship to the patient.
11. If necessary, have a witness or interpreter sign where indicated, also including the date and time.
12. Finally, review all entered information for accuracy, then save changes, download, print, or share the completed form as needed.

Complete your documents online today for a seamless experience.