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- Medical Records Request Forms | UC Davis Health
Here you'll find information regarding Health Information Management's Release of Information services Forms and information regarding how to request your medical records can be found on the right side of this page
- AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Please specify the health information you authorize to be released: :J MEDICAL o MENTAL REALTH (other than psychotherapy notes) Type(s) of health information: _____________________ ( Date(s) of treatment_______________________,
- PATIENT NAME: UC DAVIS HEALTH DATE OF BIRTH: SACRAMENTO, CALIFORNIA UC . . .
Records limited to the following provider(s) or department(s): ______________________________________ further authorize the release of information for treatment provided after the date of signature on this authorization, as long as such treatment occurs while this authorization has not expired _______ (initials)
- HIM Release of Information
Your Rights: This authorization to release health information in voluntary Treatment, payment, enrollment or eligibility for benefits may not be conditioned on signing this form
- AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION
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
- HIM Release of Information - UC Davis Health
Records limited to the following provider(s) or department(s): ______________________________________ further authorize the release of information for treatment provided after the date of signature on this authorization, as long as such treatment occurs while this authorization has not expired _______ (initials)
- Release of Information - UC Davis Health
Here you'll find information regarding Health Information Management's Release of Information services Forms and information regarding how to request your medical records can be found on the right side of this page
- UC Davis Health Release of Images
Find forms and information on how to request medical records from the Health Information Management Department at UC Davis Health
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