university of utah medical records release form

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UChicago Medicine Ingalls Memorial Complete the Request for Medical Records form (below) to make your pick-up request. 0000026343 00000 n Please provide an email address on your release form and once the records are prepared, we will release to your preference. The Michigan Medicine Release of Information office is currently closed to walk-in services. You may fax, mail, or personally deliver your completed form to OU Health Services. This box must be checked for ALL releases of records authorized by legal representatives. 0000015021 00000 n endstream endobj 56 0 obj << /Type /Annot /Subtype /Widget /Rect [ 74.5 331.5 99 342.5 ] /F 4 /P 35 0 R /DA (��vn��XP=5�) /MK << /BC [ 0 0 0 ] /BG [ 1 1 1 ] /CA (�)>> /AS /Off /AP << /N << /Yes 59 0 R /Off 60 0 R >> /D << /Yes 57 0 R /Off 58 0 R >> >> /T (��rF��Y) /FT /Btn >> endobj 57 0 obj << /Length 135 /Subtype /Form /BBox [ 0 0 24.5 11 ] /Resources << /ProcSet [ /PDF /Text ] /Font << /ZaDb 48 0 R >> >> >> stream �q��L�G�k��Ao�&�T��C�\�q,9�S��l�y��B��ڽ��˳F_(�ۚ��vQ��2��xA/w/yÖӦK endstream endobj 60 0 obj << /Length 49 /Subtype /Form /BBox [ 0 0 24.5 11 ] /Resources << /ProcSet [ /PDF ] >> >> stream Mail or fax this form: Mail to: UVA Health Release of Information, Health Information Services P.O. How can I obtain a copy of my medical record? To help prevent the spread of germs in our community and promote social distancing, UMC’s Health Information Management Department (HIM) has introduced a new temporary policy for obtaining copies of medical records. What format — either electronic or paper — you want your records. �8mI_;�!~ endstream endobj 83 0 obj << /Length 53 /Subtype /Form /BBox [ 0 0 24.5 11 ] /Resources << /ProcSet [ /PDF ] >> >> stream All Records Radiology Reports . 0000023337 00000 n 0000006233 00000 n To start your request, simply download, print, complete, and sign the Authorization for Disclosure of Protected Health Information Form.Fax or mail it back to us, to the attention of the Health Information Management Office. ��(��;��~�"c(a�?�b�N�� Records not available through the patient portal can be obtained by contacting the … 0000018306 00000 n 0000006141 00000 n When you compose a medical records release form, or download one online, make sure it has the basic elements which include: An explicit opening statement which states the intent to release confidential health information, or PHI to an organization or medical professional. 0000003273 00000 n What format — either electronic or paper — you want your records. �b0�=�Z�,��Y��]��0�j3�Q��r��n�C@�wf� �.aꆇ��p쬄�J�a��݂��k�OZ-T�,T��e�Sn��N�~Q߼a��E��QW�gVM�w�J��h�g܃66� endstream endobj 50 0 obj << /Length 49 /Subtype /Form /BBox [ 0 0 24.5 11 ] /Resources << /ProcSet [ /PDF ] >> >> stream 0000013520 00000 n Most people just need a portion of their record, though you can get your whole record if needed.Please note on the form exactly what information you need. Download the Medical Records Release Form. For physician office records, please contact the office. +�h�ڑnK ށ��c�'��7$v��`�|��A�2�&�5eYE�� endstream endobj 86 0 obj << /Type /Annot /Subtype /Widget /Rect [ 199.5 295 557 308 ] /F 4 /P 35 0 R /Ff 4194304 /T (�3��) /FT /Tx >> endobj 87 0 obj << /Type /Annot /Subtype /Widget /Rect [ 73 277 97.5 288 ] /F 4 /P 35 0 R /DA (�\\�#��Ac�+:) /MK << /BC [ 0 0 0 ] /BG [ 1 1 1 ] /CA (�)>> /AS /Off /AP << /N << /Yes 90 0 R /Off 91 0 R >> /D << /Yes 88 0 R /Off 89 0 R >> >> /T (�o��) /FT /Btn >> endobj 88 0 obj << /Length 135 /Subtype /Form /BBox [ 0 0 24.5 11 ] /Resources << /ProcSet [ /PDF /Text ] /Font << /ZaDb 48 0 R >> >> >> stream �h��}oR�I�7�8�_�}��$žQ�ΧG��a�y�� {��p��{��G�v:��K�V�=��Wt��r��4��P�n7L!�*`´J ۮ��21i�MOO��s�j�6�F�[Z�� endstream endobj 78 0 obj << /Length 53 /Subtype /Form /BBox [ 0 0 24.5 11 ] /Resources << /ProcSet [ /PDF ] >> >> stream Sign and add the date to avoid delays in processing your request provided. 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