Fillable AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (University of California, Los Angeles)

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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (University of California, Los Angeles)

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AUTHORIZATION FOR RELEASE
OF HEALTH INFORMATION
MRN:
Patient Name:
(Patient Label)
Patient
Information
Patient Name: ________________________________MRN: _________________
Address: ________________________________________________________
City, State & Zip Code: _____________________________________________
Date of Birth (MMDDYYYY): _________________Phone: ( )_______________
Specify
Healthcare
Facility
UCLA Health Hospitals/Clinics
Jules Stein Eye Institute
Resnick Neuropsychiatric Hospital
Release
Records to
Where do
you want
records
sent?
Who do you
want to
receive
records?
I authorize UCLA Health to release PHI to:
Name of Hospital/Clinic/Person: ________________________________________
Address: __________________________________________________________
City, State & Zip Code: ______________________________________________
Phone: ( )_______________ FAX: ( )_______________
E-Mail Address: ____________________________________________________
If you would like a designee* to pick up your records, please fill out section below:
I authorize ________________________________ to pick up my medical record
copies.
Relationship to patient: __________________
*Note: Designee must provide valid photo ID
Delivery
Instructions
(please
select one)
CD E-Mail (NPH/BHS does not release via email) Paper Copy
Call Requestor when records are ready for pick up
Note: If left blank, a CD will be provided.
Purpose
What is the
purpose of
this release?
At the request of the patient/patient representative
Other (state reason)
________________________________________________
Health
Information
to be
Released:
What
records are
being
requested?
Type of Records:
Medical Records
Mental Health (other than psychotherapy notes)
Billing Statements
Emergency Reports (ER)
Pathology Reports
Consultations
History & Physical Exams
Progress Notes
Discharge Summary
Jules Stein Images
Radiology Images
(x-rays)
EEG Video
Laboratory Reports
EKG
Operative Reports
Radiology Reports
Other:
UCLA Form #30910_ (Rev 12/19)
Page 1 of 2
AUTHORIZATION FOR RELEASE
OF HEALTH INFORMATION
MRN:
Patient Name:
(Patient Label)
Sensitive
Information
Sensitive information will not be released unless specifically authorized
below:
Drug and Alcohol Abuse Results
HIV/AIDS Test Results
Genetic Testing Information
Psychological/Vocational Results
Specify
Date/Time
Period
SPECIFY DATE / TIME PERIOD FOR INFORMATION SELECTED ABOVE:
FROM MM / DD / YYYY TO MM / DD / YYYY
Expiration of
Authorization
Unless otherwise revoked, this Authorization expires __________________ (insert
applicable date or event).
If no date is indicated this Authorization will expire 12 months after the date signed.
Signature(s)
__________________________________________ _____________________
(Signature of Patient / Legal Representative) Date
__________________________________________ _____________________
Printed Name Area Code/Phone Number
I
f signed by someone other than the patient, indicate relationship to the
patient ____________________________________
__________________________________________ _____________________
Signature of Witness (only if patient unable to sign) Date
or Interpreter | Interpreter ID #_____________
Mailing Addresses
Please check box for medical records
Please check box for radiology images
UCLA HIMS, Release of Information
10833 Le Conte Ave, CHS BH-902
Los Angeles, CA. 90095-1776
Fax: (310) 983-1468 | Phone: (310) 825-6021
Email: roi@mednet.ucla.edu
Image Management, Release of Information
200 Medical Plaza
B1- Level | Suite 165-11
Los Angeles Ca. 90095
Fax 310-825-3205 | Phone 310-825-6425
Please check box for mental health records
Mental Health Records
RNPH/BHS HIMS
10833 Le Conte Ave BH239A
Los Angeles CA 90095
Fax 310-206-7682 | Phone 310-267-2661 or 310-794-1530
Release of Information Customer Service – Walk-in Service
Open Hours
8a-4:30pm
Closed Lunch
11:30a-12:30p
Ronald Reagan UCLA: 100 Med Plaza, Suite 140, Los Angeles, CA 90095
Phone: (310) 825-6021 | Fax: (310) 983-1468 | Email: roi@mednet.ucla.edu
Santa Monica UCLA: 1260 – 15
th
Street, Suite 802B, Santa Monica, CA 90404
Phone: (424) 259-8045 | Fax: (310) 983-1468 | Email: roi@mednet.ucla.edu
UCLA Form #30910_(Rev 12/19)
Page 2 of 2
AUTHORIZATION FOR RELEASE
OF HEALTH INFORMATION
MRN:
Patient Name:
(Patient Label)
COMPLETING AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION
To protect our patient’s confidential medical information we must have a valid, complete and legible
authorization to disclose their health information.
All sections of this authorization must be completely filled out before UCLA Health is permitted to
disclose your protected health information.
Notice
UCLA Health and many other organizations and individuals such as physicians, hospitals and
health plans are required by law to keep your health information confidential. If you have authorized
the disclosure of your health information to someone who is not legally required to keep it
confidential, it may no longer be protected by state or federal confidentiality laws.
Revocation
I may revoke this authorization at any time, provide that I do so in writing and submit it to:
UCLA Health
Health Information Management Services
10833 Le Conte Avenue, CHS BH-902
Los Angeles, CA 90095-7305
The revocation will take effect when UCLA Health receives it, except to the extent that UCLA Health
or others have already relied on it.
My Rights
I understand this authorization is voluntary. Treatment, payment enrollment or eligibility for benefits
may not be conditioned on signing this authorization except if the authorization is for:
1) conducting research-related treatment,
2) obtaining information in connection with eligibility or enrollment in a health plan,
3) determining an entity’s obligation to pay a claim, or
4) creating PHI to provide to a third party.
I am entitled to receive a copy of this Authorization.
UCLA Form #30910_(Rev 12/19) - NOT PART OF THE LEGAL MEDICAL RECORD -
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AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION (University of California, Los Angeles)

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Completed 23 August 2021

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