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
If 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
Request medical records via myUCLAhealth
Visit our website for information:
https://www.uclahealth.org/medical-records
Call for Assistance: 855-364-7052
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
UCLA Form #30910_(Rev 01/21)
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