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Authorization for UW Medicine to Use or Disclose Protected ...

depts.washington.edu

Instructions for Completing . Patient Authorizationto Disclose, Release or Obtain . Protected Health Information . Item #1 (Patient Information): The name, birthdate, phone number and Medical Record Number (if known) of the patient.

  Name, Patients, Record, Number, Authorization, Record number

Medical Record Number: Patient Name: AUTHORIZATION …

www.uclahealth.org

AUTHORIZATION FOR RELEASE OF (PHI) PROTECTED HEALTH INFORMATION SSN (Last Four Digits UCLA Form #30910 Rev. (02/14) Page 1 of 2

  Name, Patients, Record, Number, Authorization, Patient name, Record number

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AUTHORIZATION, Patient, Name, Number, Record Number, Record Number: Patient Name: AUTHORIZATION