Transcription of Medical Record Number: Patient Name: AUTHORIZATION …
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Medical Record Number: Patient Name: AUTHORIZATION …
AUTHORIZATION FOR release OF (PHI) PROTECTED HEALTH information UCLA Form #30910 Rev. (02/14) Page 1 of 2 Medical Record number : Patient name : Birth Date: SSN (Last Four Digits Only): I would like to: request a PAPER copy -OR- request an ELECTRONIC copy (CD) SPECIFY HEALTHCARE FACILITY FROM WHICH PHI IS REQUESTED Ronald Reagan UCLA Medical Center UCLA Medical Center Santa Monica Resnick Neuropsychiatric Hospital Semel Neuropsychiatric Institute Home Health Jules Stein Eye Institute Clinic _____ (Specify name of Clinic) TYPE OF RECORDS Medical MENTAL HEALTH (other than psychotherapy notes)
AUTHORIZATION FOR RELEASE OF (PHI) PROTECTED HEALTH INFORMATION SSN (Last Four Digits UCLA Form #30910 Rev. (02/14) Page 1 of 2
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