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
The purpose of this request is for: New Access Access Renewal - UC Davis release all health information in my medical record that is available via MyUCDavisHealth MyUCDavisHealth Bedside This includes releasing content related to drug and alcohol abuse, mental health, HIV AIDS test results, resear